elective cesarean section breech presentation

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Caesarean Section

• Shoulder Dystocia
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Original Author(s): Oliver Jones Last updated: 20th December 2022 Revisions: 13

• 1 Classification
• 2 Indications
• 3.1 Pre-Operative
• 3.2 Anaesthesia
• 3.3 Operative Procedure
• 3.4 Post-Operative
• 4 Vaginal Birth After Caesarean Section (VBAC)
• 5 Complications

A C aesarean section is the delivery of a baby through a surgical incision in the abdomen and uterus.

In this article, we shall look at the classification of Caesarean sections, its indications, and an outline of the operative procedure.

Classification

A Caesarean section can be classified as either ‘ elective ’ (planned) or ‘ emergency ’.

Emergency Caesarean sections can then be subclassified into three categories, based on their urgency. This is to ensure that babies are delivered in a timely manner in accordance to their or their mother’s needs.

The Royal College of Obstetricians and Gynaecologists (RCOG) recommends that when a Category 1 section is called, the baby should be born within 30 minutes (although some units would expect 20 minutes). For Category 2 sections, there is not a universally accepted time, but usual audit standards are between 60-75 minutes.

Emergency Caesarean sections are most commonly for failure to progress in labour or suspected/confirmed fetal compromise.

Indications

A planned or ‘ elective’ Caesarean section is performed for a variety of indications. The following are the most common, but this is not an exhaustive list:

• Breech presentation  (at term) – planned Caesarean sections for breech presentation at term have increased significantly since the ‘Term Breech Trial’ [ Lancet, 2000 ].
• Other malpresentations  – e.g. unstable lie (a presentation that fluctuates from oblique, cephalic, transverse etc.), transverse lie or oblique lie.
• Twin   p regnancy – when the first twin is not a cephalic presentation.
• Maternal medical conditions  (e.g. cardiomyopathy) – where labour would be dangerous for the mother.
• Fetal compromise (such as early onset growth restriction and/or abnormal fetal Dopplers) – where it is thought the fetus would not cope with labour.
• Transmissible disease (e.g. poorly controlled HIV).
• Primary genital herpes (herpes simplex virus) in the third trimester – as there has been no time for the development and transmission of maternal antibodies to HSV to cross the placenta and protect the baby.
• Placenta praevia – ‘Low-lying placenta’ where the placenta covers, or reaches the internal os of the cervix.
• Maternal diabetes with a baby estimated to have a fetal weight >4.5 kg.
• Previous major shoulder dystocia .
• Previous 3 rd /4 th degree perineal tear where the patient is symptomatic – after discussion with the patient and appropriate assessment.
• Maternal request – this covers a variety of reasons from previous traumatic birth to ‘maternal choice’. This decision is after a multidisciplinary approach including counselling by a specialist midwife.

Elective Caesarean sections are usually planned after 39 weeks of pregnancy to reduce respiratory distress in the neonate –  known as Transient Tachypnoea of the Newborn (TTN).

For those where delivery needs to be expedited prior to 39 weeks’ gestation, the administration of corticosteroids to the mother should be considered. This stimulates development of surfactant in the fetal lungs.

Fig 1 – The different types of breech presentation. Breech at term is an indication for a Caesarean section.

Theatre Procedure

Pre-operative.

Before a Caesarean section, there are a number of basic steps that should be performed:

• The average blood loss at Caesarean section is approximately 500-1000ml, depending on many factors, especially the urgency of the operation.
• Pregnant women lying flat for a Caesarean section are at risk of Mendelson’s syndrome (aspiration of gastric contents into the lung), leading to a chemical pneumonitis. This is because of pressure applied by the gravid uterus on the gastric contents.
• Anti-thromboembolic stockings +/- low molecular weight heparin should be prescribed as appropriate.

Anaesthesia

The majority of Caesarean sections are performed under regional anaesthetic – this is usually a ‘topped-up’ epidural or a spinal anaesthetic.

Sometimes a general anaesthetic is required. The can be because of a maternal contraindication to regional anaesthetic, failure of reginal anaesthesia to achieve the required block, or more commonly because of concerns about fetal wellbeing and the need to expedite delivery as soon as possible (often the case for Category 1 sections).

Fig 2 – Epidural anaesthesia is often used in elective Caesarean section.

Operative Procedure

The woman is positioned with a left lateral tilt of 15°  – to reduce the risk of supine hypotension due to aortocaval compression.

An indwelling Foley’s catheter is inserted when the anaesthetic is ready, to drain the bladder and to reduce the risk of bladder injury during the procedure.

The skin is then prepared using an antiseptic solution and antibiotics are administered just prior to the ‘knife to skin’ incision.

There are multiple ways to perform a Caesarean, but what follows is a standard technique:

• Skin incision is usually with either a Pfannenstiel or Joel-Cohen – these are both transverse lower abdominal skin incisions.
• Camper’s fascia (superficial fatty layer of subcutaneous tissue)
• Scarpa’s fascia, (deep membranous layer of subcutaneous tissue)
• Rectus sheath, (anterior and posterior leaves laterally, that merge medially)
• Rectus muscle,
• Abdominal peritoneum (parietal)
• This reveals the gravid uterus.
• The visceral peritoneum covering the lower segment of the uterus is then incised and pushed down to reflect the bladder, which is retracted by the Doyen retractor.
• De Lee’s incision (lower vertical) may be required if the lower uterine incision is poorly formed (rare).
• Oxytocin 5 units  is given intravenously by the anaesthetist to aid delivery of the placenta by controlled cord traction by the surgeon.
• The uterine cavity is ensured empty, then closed with two layers. The rectus sheath is then closed and then the skin (either with continuous/interrupted sutures or staples).

Post-Operative

After the Caesarean section, observations are recorded on an early warning score chart, and lochia (per vaginal blood loss post delivery) is monitored.

Early mobilisation , eating and drinking and removal of catheter is encouraged to enhance recovery.

Vaginal Birth After Caesarean Section (VBAC)

In women who have had one Caesarean section, any subsequent pregnancies should be counselled regarding the risks of vaginal birth:

• A planned VBAC is associated with a one in 200 (0.5%) risk of uterine scar rupture.
• The risk of perinatal death is low and comparable to the risk of women labouring with their first child.
• There is a small increased risk of placenta praevia +/- accreta in future pregnancies, and of pelvic adhesions.
• The success rate of planned VBAC is 72–75%, however this is as high as 85-90% in women who have had a previous vaginal delivery.
• All women undergoing VBAC should have continuous electronic fetal monitoring by CTG in labour as a change in fetal heart rate can be the first sign of impending scar rupture.
• Risks of scar rupture is higher in labours that are augmented or induced with prostaglandins or oxytocin.

Complications

A primary Caesarean section carries a reduced risk of perineal trauma and pain, urinary and anal incontinence, uterovaginal prolapse, late stillbirth and early neonatal infections (compared with vaginal birth).

However, it is associated with immediate, intermediate and late complications, which are listed below:

• Breech presentation  (at term) - planned Caesarean sections for breech presentation at term have increased significantly since the ‘Term Breech Trial’ [ Lancet, 2000 ].
• Other malpresentations  - e.g. unstable lie (a presentation that fluctuates from oblique, cephalic, transverse etc.), transverse lie or oblique lie.
• Twin   p regnancy - when the first twin is not a cephalic presentation.
• Maternal medical conditions  (e.g. cardiomyopathy) - where labour would be dangerous for the mother.
• Fetal compromise (such as early onset growth restriction and/or abnormal fetal Dopplers) - where it is thought the fetus would not cope with labour.
• Primary genital herpes (herpes simplex virus) in the third trimester - as there has been no time for the development and transmission of maternal antibodies to HSV to cross the placenta and protect the baby.
• Previous 3 rd /4 th degree perineal tear where the patient is symptomatic - after discussion with the patient and appropriate assessment.
• Maternal request - this covers a variety of reasons from previous traumatic birth to 'maternal choice'. This decision is after a multidisciplinary approach including counselling by a specialist midwife.

Elective Caesarean sections are usually planned after 39 weeks of pregnancy to reduce respiratory distress in the neonate -  known as Transient Tachypnoea of the Newborn (TTN).

The majority of Caesarean sections are performed under regional anaesthetic - this is usually a ‘topped-up’ epidural or a spinal anaesthetic.

The woman is positioned with a left lateral tilt of 15°  - to reduce the risk of supine hypotension due to aortocaval compression.

The skin is then prepared using an antiseptic solution and antibiotics are administered just prior to the 'knife to skin’ incision.

• Skin incision is usually with either a Pfannenstiel or Joel-Cohen - these are both transverse lower abdominal skin incisions.
• Camper's fascia (superficial fatty layer of subcutaneous tissue)
• Scarpa's fascia, (deep membranous layer of subcutaneous tissue)
• De Lee's incision (lower vertical) may be required if the lower uterine incision is poorly formed (rare).

[start-clinical]

[end-clinical]

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Breech Presentation

• Author: Richard Fischer, MD; Chief Editor: Ronald M Ramus, MD  more...
• Sections Breech Presentation
• Vaginal Breech Delivery
• Cesarean Delivery
• Comparative Studies
• External Cephalic Version
• Conclusions
• Media Gallery

Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22-25% of births prior to 28 weeks' gestation to 7-15% of births at 32 weeks' gestation to 3-4% of births at term. [ 1 ]

Predisposing factors for breech presentation include prematurity , uterine malformations or fibroids, polyhydramnios , placenta previa , fetal abnormalities (eg, CNS malformations, neck masses, aneuploidy), and multiple gestations . Fetal abnormalities are observed in 17% of preterm breech deliveries and in 9% of term breech deliveries.

Perinatal mortality is increased 2- to 4-fold with breech presentation, regardless of the mode of delivery. Deaths are most often associated with malformations, prematurity, and intrauterine fetal demise .

Types of breeches

The types of breeches are as follows:

Frank breech (50-70%) - Hips flexed, knees extended (pike position)

Complete breech (5-10%) - Hips flexed, knees flexed (cannonball position)

Footling or incomplete (10-30%) - One or both hips extended, foot presenting

Historical considerations

Vaginal breech deliveries were previously the norm until 1959 when it was proposed that all breech presentations should be delivered abdominally to reduce perinatal morbidity and mortality. [ 2 ]

Vaginal breech delivery

Three types of vaginal breech deliveries are described, as follows:

Spontaneous breech delivery: No traction or manipulation of the infant is used. This occurs predominantly in very preterm, often previable, deliveries.

Assisted breech delivery: This is the most common type of vaginal breech delivery. The infant is allowed to spontaneously deliver up to the umbilicus, and then maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head.

Total breech extraction: The fetal feet are grasped, and the entire fetus is extracted. Total breech extraction should be used only for a noncephalic second twin; it should not be used for a singleton fetus because the cervix may not be adequately dilated to allow passage of the fetal head. Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%. Total breech extractions are sometimes performed by less experienced accoucheurs when a foot unexpectedly prolapses through the vagina. As long as the fetal heart rate is stable in this situation, it is permissible to manage expectantly to allow the cervix to completely dilate around the breech (see the image below).

Technique and tips for assisted vaginal breech delivery

The fetal membranes should be left intact as long as possible to act as a dilating wedge and to prevent overt cord prolapse .

Oxytocin induction and augmentation are controversial. In many previous studies, oxytocin was used for induction and augmentation, especially for hypotonic uterine dysfunction. However, others are concerned that nonphysiologic forceful contractions could result in an incompletely dilated cervix and an entrapped head.

An anesthesiologist and a pediatrician should be immediately available for all vaginal breech deliveries. A pediatrician is needed because of the higher prevalence of neonatal depression and the increased risk for unrecognized fetal anomalies. An anesthesiologist may be needed if intrapartum complications develop and the patient requires general anesthesia .

Some clinicians perform an episiotomy when the breech delivery is imminent, even in multiparas, as it may help prevent soft tissue dystocia for the aftercoming head (see the images below).

The Pinard maneuver may be needed with a frank breech to facilitate delivery of the legs but only after the fetal umbilicus has been reached. Pressure is exerted in the popliteal space of the knee. Flexion of the knee follows, and the lower leg is swept medially and out of the vagina.

No traction should be exerted on the infant until the fetal umbilicus is past the perineum, after which time maternal expulsive efforts should be used along with gentle downward and outward traction of the infant until the scapula and axilla are visible (see the image below).

Use a dry towel to wrap around the hips (not the abdomen) to help with gentle traction of the infant (see the image below).

An assistant should exert transfundal pressure from above to keep the fetal head flexed.

Once the scapula is visible, rotate the infant 90° and gently sweep the anterior arm out of the vagina by pressing on the inner aspect of the arm or elbow (see the image below).

Rotate the infant 180° in the reverse direction, and sweep the other arm out of the vagina. Once the arms are delivered, rotate the infant back 90° so that the back is anterior (see the image below).

The fetal head should be maintained in a flexed position during delivery to allow passage of the smallest diameter of the head. The flexed position can be accomplished by using the Mauriceau Smellie Veit maneuver, in which the operator's index and middle fingers lift up on the fetal maxillary prominences, while the assistant applies suprapubic pressure (see the image below).

Alternatively, Piper forceps can be used to maintain the head in a flexed position (see the image below).

In many early studies, routine use of Piper forceps was recommended to protect the head and to minimize traction on the fetal neck. Piper forceps are specialized forceps that are placed from below the infant and, unlike conventional forceps, are not tailored to the position of the fetal head (ie, it is a pelvic, not cephalic, application). The forceps are applied while the assistant supports the fetal body in a horizontal plane.

During delivery of the head, avoid extreme elevation of the body, which may result in hyperextension of the cervical spine and potential neurologic injury (see the images below).

Lower Apgar scores, especially at 1 minute, are more common with vaginal breech deliveries. Many advocate obtaining an umbilical cord artery and venous pH for all vaginal breech deliveries to document that neonatal depression is not due to perinatal acidosis.

Fetal head entrapment may result from an incompletely dilated cervix and a head that lacks time to mold to the maternal pelvis. This occurs in 0-8.5% of vaginal breech deliveries. [ 3 ] This percentage is higher with preterm fetuses (< 32 wk), when the head is larger than the body. Dührssen incisions (ie, 1-3 cervical incisions made to facilitate delivery of the head) may be necessary to relieve cervical entrapment. However, extension of the incision can occur into the lower segment of the uterus, and the operator must be equipped to deal with this complication. The Zavanelli maneuver has been described, which involves replacement of the fetus into the abdominal cavity followed by cesarean delivery. While success has been reported with this maneuver, fetal injury and even fetal death have occurred.

Nuchal arms, in which one or both arms are wrapped around the back of the neck, are present in 0-5% of vaginal breech deliveries and in 9% of breech extractions. [ 3 ] Nuchal arms may result in neonatal trauma (including brachial plexus injuries) in 25% of cases. Risks may be reduced by avoiding rapid extraction of the infant during delivery of the body. To relieve nuchal arms when it is encountered, rotate the infant so that the fetal face turns toward the maternal symphysis pubis (in the direction of the impacted arm); this reduces the tension holding the arm around the back of the fetal head, allowing for delivery of the arm.

Cervical spine injury is predominantly observed when the fetus has a hyperextended head prior to delivery. Ballas and Toaff (1976) reported 20 cases of hyperextended necks, defined as an angle of extension greater than 90° ("star-gazing"), discovered on antepartum radiographs. [ 4 ] Of the 11 fetuses delivered vaginally, 8 (73%) sustained complete cervical spinal cord lesions, defined as either transection or nonfunction.

Cord prolapse may occur in 7.4% of all breech labors. This incidence varies with the type of breech: 0-2% with frank breech, 5-10% with complete breech, and 10-25% with footling breech. [ 3 ] Cord prolapse occurs twice as often in multiparas (6%) than in primigravidas (3%). Cord prolapse may not always result in severe fetal heart rate decelerations because of the lack of presenting parts to compress the umbilical cord (ie, that which predisposes also protects).

Prior to the 2001 recommendations by the American College of Obstetricians and Gynecologists (ACOG), approximately 50% of breech presentations were considered candidates for vaginal delivery. Of these candidates, 60-82% were successfully delivered vaginally.

Candidates can be classified based on gestational age. For pregnancies prior to 26 weeks' gestation, prematurity, not mode of delivery, is the greatest risk factor. Unfortunately, no randomized clinical trials to help guide clinical management have been reported. Vaginal delivery can be considered, but a detailed discussion of the risks from prematurity and the lack of data regarding the ideal mode of delivery should take place with the parent(s). For example, intraventricular hemorrhage, which can occur in an infant of extremely low birth weight, should not be misinterpreted as proof of a traumatic vaginal breech delivery.

For pregnancies between 26 and 32 weeks, retrospective studies suggest an improved outcome with cesarean delivery, although these reports are subject to selection bias. In contrast, between 32 and 36 weeks' gestation, vaginal breech delivery may be considered after a discussion of risks and benefits with the parent(s).

After 37 weeks' gestation, parents should be informed of the results of a multicenter randomized clinical trial that demonstrated significantly increased perinatal mortality and short-term neonatal morbidity associated with vaginal breech delivery (see Comparative Studies). For those attempting vaginal delivery, if estimated fetal weight (EFW) is more than 4000 g, some recommend cesarean delivery because of concern for entrapment of the unmolded head in the maternal pelvis, although data to support this practice are limited.

A frank breech presentation is preferred when vaginal delivery is attempted. Complete breeches and footling breeches are still candidates, as long as the presenting part is well applied to the cervix and both obstetrical and anesthesia services are readily available in the event of a cord prolapse.

The fetus should show no neck hyperextension on antepartum ultrasound imaging (see the image below). Flexed or military position is acceptable.

Regarding prior cesarean delivery, a retrospective study by Ophir et al of 71 women with one prior low transverse cesarean delivery who subsequently delivered a breech fetus found that 24 women had an elective repeat cesarean and 47 women had a trial of labor. [ 5 ] In the 47 women with a trial of labor, 37 (78.7%) resulted in a vaginal delivery. Two infants in the trial of labor group had nuchal arms (1 with a transient brachial plexus injury) and 1 woman required a hysterectomy for hemorrhage due to a uterine dehiscence discovered after vaginal delivery. Vaginal breech delivery after one prior cesarean delivery is not contraindicated, though larger studies are needed.

Primigravida versus multiparous

It had been commonly believed that primigravidas with a breech presentation should have a cesarean delivery, although no data (prospective or retrospective) support this view. The only documented risk related to parity is cord prolapse, which is 2-fold higher in parous women than in primigravid women.

Radiographic and CT pelvimetry

Historically, radiograph pelvimetry was believed to be useful to quantitatively assess the inlet and mid pelvis. Recommended pelvimetry criteria included a transverse inlet diameter larger than 11.5 cm, anteroposterior inlet diameter larger than 10.5 cm, transverse midpelvic diameter (between the ischial spines) larger than 10 cm, and anteroposterior midpelvic diameter larger than 11.5 cm. However, radiographic pelvimetry is rarely, if ever, used in the United States.

CT pelvimetry , which is associated with less fetal radiation exposure than conventional radiographic pelvimetry, was more recently advocated by some investigators. It, too, is rarely used today.

Ultimately, if the obstetrical operator is not experienced or comfortable with vaginal breech deliveries, cesarean delivery may be the best choice. Unfortunately, with the dwindling number of experienced obstetricians who still perform vaginal breech deliveries and who can teach future generations of obstetricians, this technique may soon be lost due to attrition.

In 1970, approximately 14% of breeches were delivered by cesarean delivery. By 1986, that rate had increased to 86%. In 2003, based on data from the National Center for Health Statistics, the rate of cesarean delivery for all breech presentations was 87.2%. Most of the remaining breeches delivered vaginally were likely second twins, fetal demises, and precipitous deliveries. However, the rise in cesarean deliveries for breeches has not necessarily equated with an improvement in perinatal outcome. Green et al compared the outcome for term breeches prior to 1975 (595 infants, 22% cesarean delivery rate for breeches) with those from 1978-1979 (164 infants, 94% cesarean delivery rate for breeches). [ 6 ] Despite the increase in rates of cesarean delivery, the differences in rates of asphyxia, birth injury, and perinatal deaths were not significant.

Maneuvers for cesarean delivery are similar to those for vaginal breech delivery, including the Pinard maneuver, wrapping the hips with a towel for traction, head flexion during traction, rotation and sweeping out of the fetal arms, and the Mauriceau Smellie Veit maneuver.

An entrapped head can still occur during cesarean delivery as the uterus contracts after delivery of the body, even with a lower uterine segment that misleadingly appears adequate prior to uterine incision. Entrapped heads occur more commonly with preterm breeches, especially with a low transverse uterine incision. As a result, some practitioners opt to perform low vertical uterine incisions for preterm breeches prior to 32 weeks' gestation to avoid head entrapment and the kind of difficult delivery that cesarean delivery was meant to avoid. Low vertical incisions usually require extension into the corpus, resulting in cesarean delivery for all future deliveries.

If a low transverse incision is performed, the physician should move quickly once the breech is extracted in order to deliver the head before the uterus begins to contract. If any difficulty is encountered with delivery of the fetal head, the transverse incision can be extended vertically upward (T incision). Alternatively, the transverse incision can be extended laterally and upward, taking great care to avoid trauma to the uterine arteries. A third option is the use of a short-acting uterine relaxant (eg, nitroglycerin) in an attempt to facilitate delivery.

Only 3 randomized studies have evaluated the mode of delivery of the term breech. All other studies were nonrandomized or retrospective, which may be subject to selection bias.

In 1980, Collea et al randomized 208 women in labor with term frank breech presentations to either elective cesarean delivery or attempted vaginal delivery after radiographic pelvimetry. [ 7 ] Oxytocin was allowed for dysfunctional labor. Of the 60 women with adequate pelves, 49 delivered vaginally. Two neonates had transient brachial plexus injuries. Women randomized to elective cesarean delivery had higher postpartum morbidity rates (49.3% vs 6.7%).

In 1983, Gimovsky et al randomized 105 women in labor with term nonfrank breech presentations to a trial of labor versus elective cesarean delivery. [ 8 ] In this group of women, 47 had complete breech presentations, 16 had incomplete breech presentations (hips flexed, 1 knee extended/1 knee flexed), 32 had double-footling presentations, and 10 had single-footling presentations. Oxytocin was allowed for dysfunctional labor. Of the labor group, 44% had successful vaginal delivery. Most cesarean deliveries were performed for inadequate pelvic dimensions on radiographic pelvimetry. The rate of neonatal morbidity did not differ between neonates delivered vaginally and those delivered by cesarean delivery, although a higher maternal morbidity rate was noted in the cesarean delivery group.

In 2000, Hannah and colleagues completed a large, multicenter, randomized clinical trial involving 2088 term singleton fetuses in frank or complete breech presentations at 121 institutions in 26 countries. [ 9 ] In this study, popularly known as the Term Breech Trial, subjects were randomized into a planned cesarean delivery group or a planned vaginal birth group. Exclusion criteria were estimated fetal weight (EFW) more than 4000 g, hyperextension of the fetal head, lethal fetal anomaly or anomaly that might result in difficulty with delivery, or contraindication to labor or vaginal delivery (eg, placenta previa ).

Subjects randomized to cesarean delivery were scheduled to deliver after 38 weeks' gestation unless conversion to cephalic presentation had occurred. Subjects randomized to vaginal delivery were treated expectantly until labor ensued. Electronic fetal monitoring was either continuous or intermittent. Inductions were allowed for standard obstetrical indications, such as postterm gestations. Augmentation with oxytocin was allowed in the absence of apparent fetopelvic disproportion, and epidural analgesia was permitted.

Adequate labor was defined as a cervical dilation rate of 0.5 cm/h in the active phase of labor and the descent of the breech fetus to the pelvic floor within 2 hours of achieving full dilation. Vaginal delivery was spontaneous or assisted and was attended by an experienced obstetrician. Cesarean deliveries were performed for inadequate progress of labor, nonreassuring fetal heart rate, or conversion to footling breech. Results were analyzed by intent-to-treat (ie, subjects were analyzed by randomization group, not by ultimate mode of delivery).

Of 1041 subjects in the planned cesarean delivery group, 941 (90.4%) had cesarean deliveries. Of 1042 subjects in the planned vaginal delivery group, 591 (56.7%) had vaginal deliveries. Indications for cesarean delivery included: fetopelvic disproportion or failure to progress in labor (226), nonreassuring fetal heart rate tracing (129), footling breech (69), request for cesarean delivery (61), obstetrical or medical indications (45), or cord prolapse (12).

The composite measurement of either perinatal mortality or serious neonatal morbidity by 6 weeks of life was significantly lower in the planned cesarean group than in the planned vaginal group (5% vs 1.6%, P < .0001). Six of 16 neonatal deaths were associated with difficult vaginal deliveries, and 4 deaths were associated with fetal heart rate abnormalities. The reduction in risk in the cesarean group was even greater in participating countries with overall low perinatal mortality rates as reported by the World Health Organization. The difference in perinatal outcome held after controlling for the experience level of the obstetrician. No significant difference was noted in maternal mortality or serious maternal morbidity between the 2 groups within the first 6 weeks of delivery (3.9% vs 3.2%, P = .35).

A separate analysis showed no difference in breastfeeding, sexual relations, or depression at 3 months postpartum, though the reported rate of urinary incontinence was higher in the planned vaginal group (7.3% vs 4.5%).

Based on the multicenter trial, the ACOG published a Committee Opinion in 2001 that stated "planned vaginal delivery of a singleton term breech may no longer be appropriate." This did not apply to those gravidas presenting in advanced labor with a term breech and imminent delivery or to a nonvertex second twin.

A follow-up study by Whyte et al was conducted in 2004 on 923 children who were part of the initial multicenter study. [ 10 ] The authors found no differences between the planned cesarean delivery and planned vaginal breech delivery groups with regards to infant death rates or neurodevelopmental delay by age 2 years. Similarly, among 917 participating mothers from the original trial, no substantive differences were apparent in maternal outcome between the 2 groups. [ 11 ] No longer-term maternal effects, such as the impact of a uterine scar on future pregnancies, have yet been reported.

A meta-analysis of the 3 above mentioned randomized trials was published in 2015. The findings included a reduction in perinatal/neonatal death, reduced composite short-term outcome of perinatal/neonatal death or serious neonatal morbidity with planned cesarean delivery versus planned vaginal delivery. [ 12 ] However, at 2 years of age, there was no significant difference in death or neurodevelopmental delay between the two groups.  Maternal outcomes assessed at 2 years after delivery were not significantly different.

With regard to preterm breech deliveries, only one prospective randomized study has been performed, which included only 38 subjects (28-36 wk) with preterm labor and breech presentation. [ 13 ] Of these subjects, 20 were randomized to attempted vaginal delivery and 18 were randomized to immediate cesarean delivery. Of the attempted vaginal delivery group, 25% underwent cesarean delivery for nonreassuring fetal heart rate tracings. Five neonatal deaths occurred in the vaginal delivery group, and 1 neonatal death occurred in the cesarean delivery group. Two neonates died from fetal anomalies, 3 from respiratory distress, and 1 from sepsis.

Nonanomalous infants who died were not acidotic at delivery and did not have birth trauma. Differences in Apgar scores were not significant, although the vaginal delivery group had lower scores. The small number of enrolled subjects precluded any definitive conclusions regarding the safety of vaginal breech delivery for a preterm breech.

Retrospective analyses showed a higher mortality rate in vaginal breech neonates weighing 750-1500 g (26-32 wk), but less certain benefit was shown with cesarean delivery if the fetal weight was more than 1500 g (approximately 32 wk). Therefore, this subgroup of very preterm infants (26-32 wk) may benefit from cesarean delivery, although this recommendation is based on potentially biased retrospective data.

A large cohort study was published in 2015 from the Netherlands Perinatal Registry, which included 8356 women with a preterm (26-36 6/7 weeks) breech from 2000 to 2011, over three quarters of whom intended to deliver vaginally. In this overall cohort, there was no significant difference in perinatal mortality between the planned vaginal delivery and planned cesarean delivery groups (adjusted odds ratio 0.97, 95% confidence interval 0.60 – 1.57).  However, the subgroup delivering at 28 to 32 weeks had a lower perinatal mortality with planned cesarean section (aOR 0.27, 95% CI 0.10 – 0.77).  After adding a composite of perinatal morbidity, planned cesarean delivery was associated with a better outcome than a planned vaginal delivery (aOR 0.77, 95% CI 0.63 – 0.93. [ 14 ]

A Danish study found that nulliparous women with a singleton breech presentation who had a planned vaginal delivery were at significantly higher risk for postoperative complications, such as infection, compared with women who had a planned cesarean delivery. This increased risk was due to the likelihood of conversion to an emergency cesarean section, which occurred in over 69% of the planned vaginal deliveries in the study. [ 15 ]

The Maternal-Fetal Medicine Units Network of the US National Institute of Child Health and Human Development considered a multicenter randomized clinical trial of attempted vaginal delivery versus elective cesarean delivery for 24- to 28-week breech fetuses. [ 16 ] However, it was not initiated because of anticipated difficulty with recruitment, inadequate numbers to show statistically significant differences, and medicolegal concerns. Therefore, this study is not likely to be performed.

External cephalic version (ECV) is the transabdominal manual rotation of the fetus into a cephalic presentation.

Initially popular in the 1960s and 1970s, ECV virtually disappeared after reports of fetal deaths following the procedure. Reintroduced to the United States in the 1980s, it became increasingly popular in the 1990s.

Improved outcome may be related to the use of nonstress tests both before and after ECV, improved selection of low-risk fetuses, and Rh immune globulin to prevent isoimmunization.

Prepare for the possibility of cesarean delivery. Obtain a type and screen as well as an anesthesia consult. The patient should have nothing by mouth for at least 8 hours prior to the procedure. Recent ultrasonography should have been performed for fetal position, to check growth and amniotic fluid volume, to rule out a placenta previa, and to rule out anomalies associated with breech. Another sonogram should be performed on the day of the procedure to confirm that the fetus is still breech.

A nonstress test (biophysical profile as backup) should be performed prior to ECV to confirm fetal well-being.

Perform ECV in or near a delivery suite in the unlikely event of fetal compromise during or following the procedure, which may require emergent delivery.

ECV can be performed with 1 or 2 operators. Some prefer to have an assistant to help turn the fetus, elevate the breech out of the pelvis, or to monitor the position of the baby with ultrasonography. Others prefer a single operator approach, as there may be better coordination between the forces that are raising the breech and moving the head.

ECV is accomplished by judicious manipulation of the fetal head toward the pelvis while the breech is brought up toward the fundus. Attempt a forward roll first and then a backward roll if the initial attempts are unsuccessful. No consensus has been reached regarding how many ECV attempts are appropriate at one time. Excessive force should not be used at any time, as this may increase the risk of fetal trauma.

Following an ECV attempt, whether successful or not, repeat the nonstress test (biophysical profile if needed) prior to discharge. Also, administer Rh immune globulin to women who are Rh negative. Some physicians traditionally induce labor following successful ECV. However, as virtually all of these recently converted fetuses are unengaged, many practitioners will discharge the patient and wait for spontaneous labor to ensue, thereby avoiding the risk of a failed induction of labor. Additionally, as most ECV’s are attempted prior to 39 weeks, as long as there are no obstetrical or medical indications for induction, discharging the patient to await spontaneous labor would seem most prudent.

In those with an unsuccessful ECV, the practitioner has the option of sending the patient home or proceeding with a cesarean delivery. Expectant management allows for the possibility of spontaneous version. Alternatively, cesarean delivery may be performed at the time of the failed ECV, especially if regional anesthesia is used and the patient is already in the delivery room (see Regional anesthesia). This would minimize the risk of a second regional analgesia.

In those with an unsuccessful ECV, the practitioner may send the patient home, if less than 39 weeks, with plans for either a vaginal breech delivery or scheduled cesarean after 39 weeks. Expectant management allows for the possibility of a spontaneous version. Alternatively, if ECV is attempted after 39 weeks, cesarean delivery may be performed at the time of the failed ECV, especially if regional anesthesia is used and the patient is already in the delivery room (see Regional anesthesia). This would minimize the risk of a second regional analgesia.

Success rate

Success rates vary widely but range from 35% to 86% (average success rate in the 2004 National Vital Statistics was 58%). Improved success rates occur with multiparity, earlier gestational age, frank (versus complete or footling) breech presentation, transverse lie, and in African American patients.

Opinions differ regarding the influence of maternal weight, placental position, and amniotic fluid volume. Some practitioners find that thinner patients, posterior placentas, and adequate fluid volumes facilitate successful ECV. However, both patients and physicians need to be prepared for an unsuccessful ECV; version failure is not necessarily a reflection of the skill of the practitioner.

Zhang et al reviewed 25 studies of ECV in the United States, Europe, Africa, and Israel. [ 17 ] The average success rate in the United States was 65%. Of successful ECVs, 2.5% reverted back to breech presentation (other estimates range from 3% to 5%), while 2% of unsuccessful ECVs had spontaneous version to cephalic presentation prior to labor (other estimates range from 12% to 26%). Spontaneous version rates depend on the gestational age when the breech is discovered, with earlier breeches more likely to undergo spontaneous version.

A prospective study conducted in Germany by Zielbauer et al demonstrated an overall success rate of 22.4% for ECV among 353 patients with a singleton fetus in breech presentation. ECV was performed at 38 weeks of gestation. Factors found to increase the likelihood of success were a later week of gestation, abundant amniotic fluid, fundal and anterior placental location, and an oblique lie. [ 18 ]

A systematic review in 2015 looked at the effectiveness of ECV with eight randomized trials of ECV at term. Compared to women with no attempt at ECV, ECV reduced non-cephalic presentation at birth by 60% and reduced cesarean sections by 40% in the same group. [ 19 ] Although the rate of cesarean section is lower when ECV is performed than if not, the overall rate of cesarean section remains nearly twice as high after successful ECV due to both dystocia and non-reassuring fetal heart rate patterns. [ 20 ]  Nulliparity was the only factor shown in follow-up to increase the risk of instrumental delivery following successful ECV. [ 21 ]

While most studies of ECV have been performed in university hospitals, Cook showed that ECV has also been effective in the private practice setting. [ 22 ] Of 65 patients with term breeches, 60 were offered ECV. ECV was successful in 32 (53%) of the 60 patients, with vaginal delivery in 23 (72%) of the 32 patients. Of the remaining breech fetuses believed to be candidates for vaginal delivery, 8 (80%) had successful vaginal delivery. The overall vaginal delivery rate was 48% (31 of 65 patients), with no significant morbidity.

Cost analysis

In 1995, Gifford et al performed a cost analysis of 4 options for breech presentations at term: (1) ECV attempt on all breeches, with attempted vaginal breech delivery for selected persistent breeches; (2) ECV on all breeches, with cesarean delivery for persistent breeches; (3) trial of labor for selected breeches, with scheduled cesarean delivery for all others; and (4) scheduled cesarean delivery for all breeches prior to labor. [ 23 ]

ECV attempt on all breeches with attempted vaginal breech delivery on selected persistent breeches was associated with the lowest cesarean delivery rate and was the most cost-effective approach. The second most cost-effective approach was ECV attempt on all breeches, with cesarean delivery for persistent breeches.

Uncommon risks of ECV include fractured fetal bones, precipitation of labor or premature rupture of membranes , abruptio placentae , fetomaternal hemorrhage (0-5%), and cord entanglement (< 1.5%). A more common risk of ECV is transient slowing of the fetal heart rate (in as many as 40% of cases). This risk is believed to be a vagal response to head compression with ECV. It usually resolves within a few minutes after cessation of the ECV attempt and is not usually associated with adverse sequelae for the fetus.

Trials have not been large enough to determine whether the overall risk of perinatal mortality is increased with ECV. The Cochrane review from 2015 reported perinatal death in 2 of 644 in ECV and 6 of 661 in the group that did not attempt ECV. [ 19 ]

A 2016 Practice Bulletin by ACOG recommended that all women who are near term with breech presentations should be offered an ECV attempt if there are no contraindications (see Contraindications below). [ 24 ]  ACOG guidelines issued in 2020 recommend that ECV should be performed starting at 37+0 weeks, in order to reduce the likelihood of reversion and to increase the rate of spontaneous version. [ 25 ]

ACOG recommends that ECV be offered as an alternative to a planned cesarean section for a patient who has a term singleton breech fetus, wishes to have a planned vaginal delivery of a vertex-presenting fetus, and has no contraindications. ACOG also advises that ECV be attempted only in settings where cesarean delivery services are available. [ 26 ]

ECV is usually not performed on preterm breeches because they are more likely to undergo spontaneous version to cephalic presentation and are more likely to revert to breech after successful ECV (approximately 50%). Earlier studies of preterm ECV did not show a difference in the rates of breech presentations at term or overall rates of cesarean delivery. Additionally, if complications of ECV were to arise that warranted emergent delivery, it would result in a preterm neonate with its inherent risks. The Early External Cephalic Version (ECV) 2 trial was an international, multicentered, randomized clinical trial that compared ECV performed at 34-35 weeks’ gestation compared with 37 weeks’ gestation or more. [ 27 ] Early ECV increased the chance of cephalic presentation at birth; however, no difference in cesarean delivery rates was noted, along with a nonstatistical increase in preterm births.

A systematic review looked at 5 studies of ECV completed prior to 37 weeks and concluded that compared with no ECV attempt, ECV commenced before term reduces the non-cephalic presentation at birth, however early ECV may increase the risk of late preterm birth. [ 28 ]

Given the increasing awareness of the risks of late preterm birth and early term deliveries, the higher success of earlier ECV should be weighed against the risks of iatrogenic prematurity should a complication arise necessitating delivery.

Contraindications

Absolute contraindications for ECV include multiple gestations with a breech presenting fetus, contraindications to vaginal delivery (eg, herpes simplex virus infection, placenta previa), and nonreassuring fetal heart rate tracing.

Relative contraindications include polyhydramnios or oligohydramnios , fetal growth restriction , uterine malformation , and major fetal anomaly.

Controversial candidates

Women with prior uterine incisions may be candidates for ECV, but data are scant. In 1991, Flamm et al attempted ECV on 56 women with one or more prior low transverse cesarean deliveries. [ 29 ] The success rate of ECV was 82%, with successful vaginal births in 65% of patients with successful ECVs. No uterine ruptures occurred during attempted ECV or subsequent labor, and no significant fetal complications occurred.

In 2010 ACOG acknowledged that although there is limited data in both the above study and one more recently, [ 30 ] no serious adverse events occurred in these series. A larger prospective cohort study that was published in 2014 reported similar success rates of ECV among women with and without prior cesarean section, although lower vaginal birth rates. There were, however, no cases of uterine rupture or other adverse outcomes. [ 31 ]

Another controversial area is performing ECV on a woman in active labor. In 1985, Ferguson and Dyson reported on 15 women in labor with term breeches and intact membranes. [ 32 ] Four patients were dilated greater than 5 cm (2 women were dilated 8 cm). Tocolysis was administered, and intrapartum ECV was attempted. ECV was successful in 11 of 15 patients, with successful vaginal births in 10 patients. No adverse effects were noted. Further studies are needed to evaluate the safety and efficacy of intrapartum ECV.

Data regarding the benefit of intravenous or subcutaneous beta-mimetics in improving ECV rates are conflicting.

In 1996, Marquette et al performed a prospective, randomized, double-blinded study on 283 subjects with breech presentations between 36 and 41 weeks' gestation. [ 33 ] Subjects received either intravenous ritodrine or placebo. The success rate of ECV was 52% in the ritodrine group versus 42% in the placebo group ( P = .35). When only nulliparous subjects were analyzed, significant differences were observed in the success of ECV (43% vs 25%, P < .03). ECV success rates were significantly higher in parous versus nulliparous subjects (61% vs 34%, P < .0001), with no additional improvement with ritodrine.

A systematic review published in 2015 of six randomized controlled trials of ECV that compared the use of parenteral beta-mimetic tocolysis during ECV concluded that tocolysis was effective in increasing the rate of cephalic presentation in labor and reducing the cesarean delivery rate by almost 25% in both nulliparous and multiparous women. [ 34 ] Data on adverse effects and other tocolytics was insufficient. A review published in 2011 on Nifedipine did not show an improvement in ECV success. [ 35 ]

Regional anesthesia

Regional analgesia, either epidural or spinal, may be used to facilitate external cephalic version (ECV) success. When analgesia levels similar to that for cesarean delivery are given, it allows relaxation of the anterior abdominal wall, making palpation and manipulation of the fetal head easier. Epidural or spinal analgesia also eliminates maternal pain that may cause bearing down and tensing of the abdominal muscles. If ECV is successful, the epidural can be removed and the patient sent home to await spontaneous labor. If ECV is unsuccessful, a patient can proceed to cesarean delivery under her current anesthesia, if the gestational age is more than 39 weeks.

The main disadvantage is the inherent risk of regional analgesia, which is considered small. Additionally, lack of maternal pain could potentially result in excessive force being applied to the fetus without the knowledge of the operator.

In 1994, Carlan et al retrospectively analyzed 61 women who were at more than 36 weeks' gestation and had ECV with or without epidural. [ 36 ] The success rate of ECV was 59% in the epidural group and 24% in the nonepidural group ( P < .05). In 7 of 8 women with unsuccessful ECV without epidural, a repeat ECV attempt after epidural was successful. No adverse effects on maternal or perinatal morbidity or mortality occurred.

In 1997, Schorr et al randomized 69 subjects who were at least 37 weeks' gestation to either epidural or control groups prior to attempted ECV. [ 37 ] Those in whom ECV failed underwent cesarean delivery. The success rate of ECV was 69% in the epidural group and 32% in the control group (RR, 2.12; 95% CI, 1.24-3.62). The cesarean delivery rate was 79% in the control group and 34% in the epidural group ( P = .001). No complications of epidural anesthesia and no adverse fetal effects occurred.

In 1999, Dugoff et al randomized 102 subjects who were at more than 36 weeks' gestation with breech presentations to either spinal anesthesia or a control group. [ 38 ] All subjects received 0.25 mg terbutaline subcutaneously. The success rate of ECV was 44% in the spinal group and 42% in the nonspinal group, which was not statistically significant.

In contrast, a 2007 randomized clinical trial of spinal analgesia versus no analgesia in 74 women showed a significant improvement in ECV success (66.7% vs 32.4%, p = .004), with a significantly lower pain score by the patient. [ 39 ]

The 2015 systematic review asserted that regional analgesia in combination with a tocolytic was more effective than the tocolytic alone for increasing ECV success; however there was no difference in cephalic presentation in labor. Data from the same review was insufficient to assess regional analgesia without tocolysis [ 34 ]

Acoustic stimulation

Johnson and Elliott performed a randomized, blinded trial on 23 subjects to compare acoustic stimulation prior to ECV with a control group when the fetal spine was in the midline (directly back up or back down). [ 40 ] Of those who received acoustic stimulation, 12 of 12 fetuses shifted to a spine-lateral position after acoustic stimulation, and 11 (91%) underwent successful ECV. In the control group, 0 of 11 shifts and 1 (9%) successful ECV ( P < .0001) occurred. Additional studies are needed.

Amnioinfusion

Although an earlier study reported on the utility of amnioinfusion to successfully turn 6 fetuses who initially failed ECV, [ 41 ] a subsequent study was published of 7 women with failed ECV who underwent amniocentesis and amnioinfusion of up to 1 liter of crystalloid. [ 42 ] Repeat attempts of ECV were unsuccessful in all 7 cases. Amnioinfusion to facilitate ECV cannot be recommended at this time.

Vaginal delivery rates after successful version

The rate of cesarean delivery ranges from 0-31% after successful external cephalic version (ECV). Controversy has existed on whether there is a higher rate of cesarean delivery for labor dystocia following ECV. In 1994, a retrospective study by Egge et al of 76 successful ECVs matched with cephalic controls by delivery date, parity, and gestational age failed to note any significant difference in the cesarean delivery rate (8% in ECV group, 6% in control group). [ 43 ]

However, in 1997, Lau et al compared 154 successful ECVs to 308 spontaneously occurring cephalic controls (matched for age, parity, and type of labor onset) with regard to the cesarean delivery rate. [ 44 ] Cesarean delivery rates were higher after ECV (16.9% vs 7.5%, P < .005) because of higher rates of cephalopelvic disproportion and nonreassuring fetal heart rate tracings. This may be related to an increased frequency of compound presentations after ECV. Immediate induction of labor after successful ECV may also contribute to an increase in the cesarean delivery rate due to failed induction in women with unripe cervices and unengaged fetal heads.

Further, in another cohort study from 2015, factors were described which decreased the vaginal delivery rate after successful ECV including labor induction, less than 2 weeks between ECV and delivery, high body mass index, and previous cesarean. [ 45 ] The overall caesarean delivery rate in this cohort was 15%.

Vaginal breech delivery requires an experienced obstetrician and careful counseling of the parents. Although studies on the delivery of the preterm breech are limited, the multicenter Term Breech Trial found an increased rate of perinatal mortality and serious immediate perinatal morbidity, though no differences were seen in infant outcome at 2 years of age.

Parents must be informed about potential risks and benefits to the mother and neonate for both vaginal breech delivery and cesarean delivery. Discussion of risks should not be limited only to the current pregnancy. The risks of a cesarean on subsequent pregnancies, including uterine rupture and placental attachment abnormalities ( placenta previa , abruption , accreta), as well as maternal and perinatal sequelae from these complications, should be reviewed as well.

It remains concerning that the dearth of experienced physicians to teach younger practitioners will lead to the abandonment of vaginal breeches altogether. For those wishing to learn the art of vaginal breech deliveries, simulation training with pelvic models has been advocated to familiarize trainees with the procedure in a nonthreatening environment. [ 46 ] Once comfortable with the appropriate maneuvers, vaginal delivery of the second, noncephalic twin, may be attempted under close supervision by an experienced physician. The cervix will already be fully dilated, and, assuming the second twin is not significantly larger, the successful vaginal delivery rate has been quoted to be as high as 96%.

External cephalic version (ECV) is a safe alternative to vaginal breech delivery or cesarean delivery, reducing the cesarean delivery rate for breech by 50%. ACOG recommends offering ECV to all women with a breech fetus near term. [ 24 ] Adjuncts such as tocolysis, regional anesthesia, and acoustic stimulation when appropriate may improve ECV success rates.

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• Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.
• Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
• Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.
• Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached.
• Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.
• Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90° in order to deliver the anterior arm.
• Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.
• Assisted vaginal breech delivery. The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the backup position in preparation for delivery of the head.
• Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.
• Piper forceps application. Piper forceps are specialized forceps used only for the after-coming head of a breech presentation. They are used to keep the fetal head flexed during extraction of the head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.
• Assisted vaginal breech delivery. Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.
• Assisted vaginal breech delivery. The neonate after birth.
• Ultrasound demonstrating a fetus in breech presentation with a hyperextended head (ie, "star gazing").

Contributor Information and Disclosures

Richard Fischer, MD Professor, Division Head, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Cooper University Hospital Richard Fischer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Society for Maternal-Fetal Medicine Disclosure: Stock ownership for: Pfizer Pharmaceuticals (< 5% of portfolio); Johnson & Johnson (< 5% of portfolio).

Alisa B Modena, MD, FACOG Assistant Professor, Cooper Medical School of Rowan University; Attending Physician, Division of Maternal-Fetal Medicine, Cooper University Hospital Alisa B Modena, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Philadelphia Perinatal Society, Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard S Legro, MD Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Society of Reproductive Surgeons , American Society for Reproductive Medicine , Endocrine Society , Phi Beta Kappa Disclosure: Received honoraria from Korea National Institute of Health and National Institute of Health (Bethesda, MD) for speaking and teaching; Received honoraria from Greater Toronto Area Reproductive Medicine Society (Toronto, ON, CA) for speaking and teaching; Received honoraria from American College of Obstetrics and Gynecologists (Washington, DC) for speaking and teaching; Received honoraria from National Institute of Child Health and Human Development Pediatric and Adolescent Gynecology Research Thi.

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Medical Society of Virginia , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

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Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies

• Lionel Carbillon   ORCID: orcid.org/0000-0001-6367-4828 1 , 2 ,
• Amelie Benbara 2 ,
• Ahmed Tigaizin 2 ,
• Rouba Murtada 2 ,
• Marion Fermaut 2 ,
• Fatma Belmaghni 2 ,
• Alexandre Bricou 2 &
• Jeremy Boujenah 2  

BMC Pregnancy and Childbirth volume  20 , Article number:  263 ( 2020 ) Cite this article

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The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies.

In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed.

The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.

Peer Review reports

The ideal management of women with term breech presentation remains a matter of intense debate. The rate of vaginal delivery has steadily declined in the last decades of the last century [ 1 ]. In 2000, the Term Breech Trial (TBT) Collaborative Group concluded that a composite variable combining perinatal and neonatal mortality or serious neonatal morbidity was significantly lower in the planned caesarean section (CS) group than in the planned vaginal birth group [ 2 ], which marked an apparent turning point in this controversy. Based on the short-term outcomes presented in the TBT study, the Royal College of Obstetricians and Gynaecologists (RCOG) [ 3 ] and the American College of Obstetricians and Gynecologists (ACOG) [ 4 ] recommended over the next few years that all women with persistent singleton breech presentation at term should undergo a planned CS delivery. An important and almost immediate impact on the practice was also observed in some countries that previously had a high proportion of vaginal breech deliveries [ 5 ]. TBT was the largest randomized trial ever published on the term breech mode of delivery. However, despite its undeniable strengths, a number of weaknesses have been identified. Specifically, there was a lack of adherence to strict criteria for vaginal birth in an important proportion of the included patients and nonoptimal methods of labour management as recognized by the TBT group itself [ 6 , 7 , 8 ]. In addition, when the TBT Collaborative Group published the 2-year analysis of paediatric outcomes, despite a large (greater than 50%) post-randomization loss to follow-up [ 9 ], these researchers found no reduction in the risk of death or neurodevelopmental delay in children at 2 years of age, thus raising questions regarding the real lessons to be drawn from this trial. Using multiple logistic regression analyses, the TBT group also reported [ 10 ] that the risk of maternal morbidity was lowest following vaginal birth (odds ratio [OR] 1.0) and highest following CS after active labour (36.1% in the TBT) (OR 3.33; 95% CI 1.75–6.33, P  < 0.001), particularly after a short second stage < 30 min (OR 0.25; 95% CI 0.11–0.57, P < 0.001) [ 9 ].

Later, population-based retrospective studies helped refine the consequences of applying recommendations of systematically planned CS for women with term breech presentation at the population level. Hartnack Tharin et al. [ 11 ] found that the rate of CS for term breech deliveries increased from 79.6 to 94.2% between 1997 and 2008 in Denmark, while intrapartum or early neonatal mortality decreased from 0.13 to 0.05% [relative risk (RR) 0.38 (95% CI 0.15–0.98)], which was a significant but lower reduction than the difference reported in the TBT. Using the Dutch National Perinatal Registry from 1999 to 2007, Vlemmix et al. [ 12 ] stated that after publication of the TBT, the elective CS rate increased from 24 to 60%, and overall perinatal mortality and short-term morbidity decreased. In contrast, these outcomes remained stable in the planned vaginal birth group. However, the authors estimated that 338 CS deliveries would need to be performed to prevent one perinatal death, and Schutte et al. [ 13 ] estimated the perinatal case fatality rate for elective CS for breech presentation in 2000–2002 at 0.47/1000 operations. At the same time, in the Netherlands the incidence of severe maternal morbidity (SMM) was estimated at 6.4/1000 during an elective CS compared with 3.9/1000 during an attempted vaginal delivery (OR 1.7; 95% CI 1.4–2.0), with an increased risk for SMM in the next pregnancy (OR 3.0; 95% CI 2.7–3.3) [ 14 ], despite the numerous facilities and adequate resources allocated to perinatal care in such a high-income country.

On the other hand, new guidelines were published in 2009 by the Society of Obstetricians and Gynaecologists of Canada (SOGC) stating that “planned vaginal delivery is reasonable in selected women with a term singleton breech foetus”. Afterwards, a study [ 15 ] including 52,671 breech deliveries in Canada (2003–2011) reported in 2011 that vaginal deliveries increased from 2.7% in 2003 to 3.9%. In this study, a concomitant increase in composite neonatal mortality and morbidity rates was observed with an adjusted rate ratio of 3.60 (95% CI 2.50–5.15), compared with CS without labour [ 15 ]. Moreover, CS with labour also increased from 8.7 to 9.8%, highlighting the particular difficulty in returning to previous practices after the clinical skills required to conduct a vaginal breech delivery have declined [ 15 , 16 ].

Some authors recently considered that “the TBT recommendations should be withdrawn” [ 6 ], while others still consider that the “results (of the TBT) are generalizable” [ 16 , 17 ]. Nevertheless, national guideline bodies have partially reversed their recommendations based on these discussions [ 18 , 19 , 20 ]. However, as rightly noted by Joseph et al. [ 16 ], the availability of clinical skills has declined in some of these countries, raising concerns from a pedagogic resident education and training standpoint [ 16 ]. In this regard, a meaningful role could be given to the possibility of training by simulation in building and maintaining specific skills and competencies for vaginal breech delivery.

A new meta-analysis [ 21 ] and several large-scale epidemiologic datasets from medical birth registries [ 22 , 23 , 24 ] recently evaluated risk factors associated with adverse perinatal outcomes in planned vaginal breech labours at term. These investigations were conducted in countries that have not abruptly modified their policies and that have continuously applied similar strict criteria over the last several decades for individual decision-making in cases of term breech presentation. We believe that the time has come to go beyond the sole question of delivery mode in the management of these situations.

Term breech presentation: are we asking the right questions?

It now appears time to expand our thinking and, considering recent important data that help elucidate the underlying significance of persistent breech presentation at term, to offer more dynamic and multidisciplinary insight into the management of these cases.

Indeed, similar to some older studies [ 25 , 26 , 27 ], several recent population-based studies [ 22 , 23 ] strongly suggest that the increased risk observed in foetuses that remain in the breech presentation at term is closely linked to antenatal or underlying disorders that may be associated with the breech presentation and is not solely due to the mode of delivery. Because adverse outcomes can be caused by underlying or gestational disorders, any discussion that is limited to delivery mode seems too restrictive and does not address the whole issue.

Most recent large-scale data

Deterministic or accidental breech presentation.

In a recent Finnish population-based case-control study including all singleton deliveries from 1 January 2005 to 31 December 2014 and excluding preterm deliveries, antepartum-diagnosed stillbirths, placenta previa and infants with congenital malformations (499,206 foetuses at term), Macharey et al. [ 22 ] evaluated the antenatal risk factors associated with adverse perinatal outcomes in planned vaginal breech labour at term. They found that the stillbirth rate was significantly higher in cases of planned vaginal breech labour than in cases of cephalic presentation (0.2 vs 0.1%, respectively), which was correlated with foetal growth restriction, oligohydramnios, gestational diabetes mellitus (GDM) and a history of CS. Furthermore, in another recent survey based on the same cohort of mother-neonate dyads that also excluded congenital malformations, placenta previa and prelabour stillbirths [ 23 ], this same group showed that breech presentation at term was significantly associated with antenatal stillbirth and a number of individual obstetric risk factors for adverse perinatal outcomes, including oligohydramnios, foetal growth restriction, gestational diabetes, history of CS section and congenital anomalies. Among all planned singleton vaginal deliveries with the foetus in the breech presentation at term, a composite adverse perinatal outcome defined as umbilical arterial pH < 7.00, 5-min Apgar score below 7 and/or neonatal mortality during the first 6 days of life (excluding stillbirth) was associated with foetal growth restriction (aOR 2.94 [1.30–6.67]), oligohydramnios (adjusted OR 2.94 [1.15–7.81]), gestational diabetes (aOR 2.89[1.54–5.40]), and a history of CS (aOR 2.94 [1.28–6.77]).

In another recent population-based study based on perinatal data of all (650,968) children born in Norway from 1999 to 2009 [ 24 ], the authors recognized the limitations of most registry-based studies, as the selection of women with breech presentation and planned vaginal delivery was based on criteria that might have identified pregnancies with a lower risk of adverse outcomes compared with those selected for CS delivery. Moreover, in this study [ 24 ], the intrapartum conversion of some of the planned vaginal deliveries to an emergency CS delivery may have increased the risk for adverse outcome in the CS group. However, Bjellmo et al. [ 24 ] conducted an innovative analysis comparing breech deliveries to vaginal cephalic births. Thus, they showed that singleton children born at term without congenital malformations had a higher risk for stillbirth and neonatal mortality if they were born in the breech presentation “regardless of whether they were born vaginally or by CS delivery” (0.9 per 1000 in those actually delivered vaginally and 0.8 per 1000 in those actually born by CS delivery) compared with those born by vaginal cephalic delivery (0.3 per 1000). Of note, among those children born in the breech rather than in the cephalic presentation, these authors [ 24 ] found that a higher proportion of infants were born small for gestational age (SGA). However, these authors [ 23 ] did not distinguish foetal growth restriction among SGA neonates. In their interpretation, Bjellmo et al. [ 23 ] considered that “the overall higher risk for stillbirth and the higher proportion of infants born SGA among children born in the breech than in the cephalic presentation may suggest that foetuses with antenatal acquired risk factors for adverse outcomes are more likely to present in the breech than in the cephalic presentation at birth.” According to these authors, the findings were most likely explained by a combination of antenatal acquired risk factors for neonatal death with increased vulnerability to the birth process. Of note, in the TBT group, birth weights of less than 2.8 kg were also associated with adverse perinatal outcomes ( P  = 0.003) [ 10 ]. In fact, a limitation in the Norwegian study [ 24 ] was that, unlike Macharey et al., the authors did not distinguish foetal growth restriction among these SGA neonates. Indeed, in a large cohort study conducted with the National Health Service region in England through a multivariable analysis of 92,218 normally formed singletons delivered during 2009–2011 from 24 weeks of gestation, including 389 stillbirths, Gardosi et al. [ 25 ] showed that foetal growth restriction had the largest population attributable risk for stillbirth which was fivefold greater if it was not detected antenatally than when it was (32.0% v 6.2%). The above data suggest that some antenatal features associated with term breech presentation, notably foetal growth restriction, and some gestational disorders (such as uncontrolled gestational diabetes mellitus) could affect the prognosis in term breech cases. Previous data also support this conclusion; Luterkort M et al. [ 26 ] had previously reported in a prospective follow-up of 228 pregnancies with the foetus in the breech presentation in the 33rd gestational week that the 96 foetuses (42%) who remained in the breech presentation at delivery weighed 4.9% less than their vertex controls after adjustments were made for gestational age and had an increased frequency of oligohydramnios. Krebs et al. [ 27 ] later confirmed this association between breech presentation and foetal growth restriction from a register-based, case-control cohort of infants with cerebral palsy born between 1979 and 1986 in East Denmark.

In fact, as reported by Fox and Chapman [ 28 ], up to 21% of all foetuses adopt a noncephalic presentation at 28–29 weeks of gestation, and this proportion progressively decreases to 5% from 37 to 38 weeks [ 28 ]. Certain conditions, such as uterine malformation, can disturb both this continuous process of spontaneous cephalic version and normal foetal growth, thereby leading to increased term breech presentation rates in these cases [ 29 ]. This point highlights the importance of estimating foetal weight and well-being in cases of persistent breech presentation at term. Furthermore, even some cases of controlled GDM may be associated with excess foetal weight during the last weeks of pregnancy, leading to possible dystocia due to this overgrowth, or with other GDM-related complications, such as preeclampsia; thus, foetal weight estimates should be monitored closely beginning in the 37th week of gestation, with regular reassessment as long as the patient has not delivered.

The impact of strict criteria on the selection of vaginal delivery

From a broad perspective, in the most recent meta-analysis investigating the risks of planned vaginal breech delivery versus planned CS for term breech birth [ 21 ], the overall heterogeneity (I 2  = 36%) was informative. The variability of neonatal mortality among 14 studies accounting for 74,094 breech vaginal deliveries was low (ranging from 0.08 to 0.37%). On the other hand, neonatal mortality was markedly higher in only 2 studies authored by Singh et al. [ 30 ] and Hannah et al. [ 2 ] (the TBT). These two studies [ 2 , 30 ] accounted for 1099 breech vaginal deliveries (1.5% of births) and had perinatal mortality rates as high as 21 and 1.3%, respectively, for planned vaginal births (25.6% of perinatal deaths). The same was true for neurological morbidity, which was 3.4 and 1%, respectively, in the studies by Singh et al. [ 30 ] and TBT [ 2 ], while it ranged from 0.07 to 0.2% in the 14 other studies encompassing 74,094 breech vaginal deliveries conducted with the implementation of more stringent exclusion criteria for vaginal breech delivery.

In these 14 studies accounting for 74,094 breech vaginal deliveries, the retrospective observational cohort study from the Finnish Medical Birth Register [ 31 ] and the prospective observational study PREMODA [ 32 ] (as well as the more recent Norwegian Medical Birth Registry study) applied similar pre-established exclusion criteria for planned vaginal birth. In the PREMODA study, an increased absolute rate of perinatal death or serious neonatal morbidity was observed in both the planned vaginal group (1.60, 95% CI 1.14–2.17) and planned CS delivery group (1.45 [1.16–1.81]) with breech presentation among the total population of 264,105 births, but the planned vaginal group and the planned CS delivery group with breech presentation did not differ significantly for the combined outcome of foetal/neonatal mortality or serious morbidity (odds ratio [OR] = 1.10, 95% CI [0.75–1.61]). The Royal College of Obstetricians and Gynaecologists proposes comparable pre-established criteria for the management of term breech presentation, recommending that “women should be informed that a higher risk of planned vaginal breech birth is expected where there are independent indications for CS section and in circumstances such as a hyperextended neck on ultrasound, high estimated foetal weight (more than 3,800 g), low estimated weight (less than tenth centile), footling presentation, [and] evidence of antenatal foetal compromise” but considers that “the role of pelvimetry is unclear” [ 20 ]. Of note concerning this last point, Van Loon et al. showed in a randomized controlled trial [ 33 ] that the adequacy of pelvis size, as assessed by pelvimetry, improved the selection of delivery route. In line with them, two recent studies support this view [ 34 , 35 ]. Other authors also included criteria for the adequate management and continuous monitoring of foetal heart rate during labour (which is common in maternity wards of most high-income countries but could be monitored intermittently in the TBT). Indeed, decreased variability and late decelerations are more prevalent during breech deliveries than vertex deliveries [ 36 ], and good labour progress is a predictor of better neonatal outcomes [ 37 ]. In the Finnish Medical Birth Register [ 31 ], 1270 women (43.6%) were selected as candidates for vaginal breech delivery, and the selection quality was confirmed by the low conversion rate of vaginal to CS breech delivery (11.4%). This rate was higher (36.1%) in the TBT [ 30 ].

As noted by methodologists [ 38 ], real-world prenatal patient care is subject to decision-making based on the continuous evaluation of risk factors, medical history, comorbidities, behavioural aspects, and other factors that indeed cannot be strictly reproduced in randomized controlled trials. For example, in the TBT [ 2 ], an upper limit of 4000–4500 g was given for estimated foetal weight. However, as the duration between randomization and delivery inevitably lengthened in the planned vaginal delivery group, a significantly higher number of macrosomic neonates were born in the planned vaginal delivery group ( P  = 0.002). In actuality, an informed woman who opts for vaginal delivery at 36 or 37 weeks of gestation usually changes her mind if she has not delivered several weeks later and if the clinician tells her that the birthweight will probably exceed 3800–4000 g, with an associated increased risk of adverse perinatal outcomes. Thus, in cases of even minor glycaemic disorder, special attention should be paid in the 37th week of gestation to foetal weight estimates and the possible occurrence of preeclampsia or associated gestational disorders; moreover, cases of SGA foetuses with possible foetal growth restriction should be closely followed, regardless of the delivery mode chosen by the patient [ 26 , 39 ].

How might we maximize patient benefit from a safe external cephalic version attempt?

With the restrictive practice of breech vaginal delivery in the last 15 years, national colleges of obstetricians (RCOG, ACOG, SOGC and RANZCOG) and FIGO updated their guidelines and recommended external cephalic version (ECV) at term to limit the increase in elective CS rate for cases of term breech presentation. However, recent data urge us to develop a broader perspective and an accurate assessment of the real impact of various ECV policies.

Indeed, the true impact of ECV may first be limited by the timely detection of breech presentation. In a retrospective cohort study of 394 consecutive cases of breech presentation at term, Hemelaar et al. [ 40 ] found that over two periods separated by 10 years (1998–1999 and 2008–2009), the proportion of breech presentations not diagnosed antenatally increased from 23.2 to 32.5% ( P  = 0.04), causing 52.8% of women who were eligible for ECV to miss an attempt in 2008–2009. The authors also reported that the proportion of women who declined ECV during the same period decreased significantly from 19.1 to 9.0%.

Eligibility is a second limitation. In Australia, a large-scale survey [ 41 ] showed that 22.3% of 32,321 singleton breech pregnancies were considered ineligible (due to oligohydramnios, antepartum haemorrhage or abruption, previous CS or pelvic abnormality, placenta previa, placenta accreta, or an infant with major congenital anomalies). In this survey [ 41 ], only 10.5% of the singleton breech pregnancies had an ECV. In a systematic review, Rosman et al. [ 42 ] identified 60 studies that reported 39 different contraindications and five guidelines with 18 contraindications (varying from five to 13 contraindications per guideline), with oligohydramnios being the only contraindication that was consistently mentioned in all guidelines. Thus, there was no general consensus on the eligibility of patients for ECV, but contraindications generally include all conditions in which this procedure may be associated with a particular risk for the foetus or mother. These conditions include the following: severe intrauterine growth restriction, abnormal umbilical artery Doppler index and/or nonreassuring foetal heart rate, which may require an emergency CS birth; foetuses with a hyperextended head and significant foetal or uterine malformations, which may carry a particular foetal risk; rhesus alloimmunization, which might be reactivated by the procedure; and recent vaginal bleeding or ruptured membranes, which were associated with cord prolapse in 33% of reported cases after ECV attempt [ 43 ].

If CS or rapid delivery is indicated for another obstetric condition, ECV is also contraindicated, notably in cases of placenta previa, severe preeclampsia, and increased risk of placental abruption. Other situations, such as maternal obesity, nonsevere SGA foetuses, and nonsevere oligohydramnios, merely decrease the likelihood of ECV success. In contexts such as severe oligohydramnios or multiple gestations, ECV is simply impracticable, except for a second twin after delivery of the first. Furthermore, previous uterine surgery (CS delivery, myomectomy, or hysteroplasty) is considered a relative contraindication for ECV by some but not all authors [ 44 ]. On the other hand, in patients with gestational diabetes mellitus, incomplete or uncontrolled glucose levels are associated with an increased risk of foetal macrosomia in late pregnancy, and even if the estimated foetal weight seems compatible with a planned vaginal delivery when the mode of delivery is discussed, rapid foetal growth during the last weeks may lead to major difficulties during delivery. Therefore, in such a context, we believe there is potential for a particular benefit from successful ECV at 36 weeks.

Predictors of successful ECV

Pinard previously observed that unengaged breech presentation is an important predictor of successful ECV [ 45 ]; the same observation was made by Lau et al. [ 46 ], Aisenbrey et al. [ 47 ], and Hutton et al. [ 48 ]. In the large series of 1776 ECVs published by Hutton et al. [ 48 ], descent and impaction of the breech foetus were the most discriminating factors for predicting successful ECV, regardless of parity. Other predictors of success include parity [ 45 , 47 , 49 , 50 ], abundant amniotic fluid [ 49 , 50 , 51 ], nonfrank breech presentation [ 47 ], gestational age under 38 weeks [ 43 ], and posterior placenta [ 50 ]. In contrast, nulliparity and tense uterus are associated with a lower likelihood of success [ 44 , 48 , 52 ].

Velzel et al. [ 53 ] recently reviewed prediction models, most of which were developed without any external validation, and found that the most reliable predictors of successful ECV were nonimpacted breech presentation, parity and uterine softness (which usually go hand in hand), normal amniotic fluid index, posterior placental location, and, as noted by Pinard [ 45 ], foetal head in a palpable situation. These criteria might be used to support patient counselling and decision-making about ECV and to reduce the proportion of women declining ECV, particularly in the most favourable situations for ECV.

Obstetric outcomes after an ECV attempt

De Hundt et al. [ 54 ] conducted a systematic review and meta-analysis and showed that women who have had a successful ECV for breech presentation are at increased risk for CS delivery (OR 2.2; 95% CI 1.6–3.0) and instrumental vaginal delivery (OR 1.4; 95% CI 1.1–1.7) compared with women with spontaneous cephalic presentation. Interestingly, stratification by time delay between successful ECV and delivery revealed a trend for increased risk of CS during the first week after ECV [ 55 ]. Furthermore, in a cohort of 301 women with successful ECV, De Hundt et al. [ 56 ] found that nulliparity was the only of seven factors that predicted the risk of CS and instrumental vaginal delivery (OR 2.7; 95% CI 1.2–6.1). Based on a retrospective, population-based cohort study using the CDC’s birth data files from the US in 2006, Balayla et al. [ 57 ] also showed that relative to breech controls without an ECV attempt, cases of ECV failure with persistent breech presentation and labour attempts were associated with increased odds of CS delivery (adjusted OR 1.38; 95% CI 1.21–1.57), assisted ventilation at birth (aOR 1.50; 95% CI 1.27–1.78), 5-min Apgar score < 7 (aOR 1.35; 95% CI 1.20–1.51), and neonatal intensive care unit admission (aOR 1.48; 95% CI 1.20–1.82).

This information should also be considered in the dialog with women regarding the way in which late pregnancy and delivery should be managed based on existing data, their own situations and their wishes.

The true benefit of an active and systematic ECV policy is widely appreciated [ 58 , 59 ], and such evaluation may be subject to bias. Burgos et al. [ 58 ] found that their policy decreased the rate of breech presentation at delivery by 39.0% and decreased the CS rate for cases of breech presentation at term from 59 to 44%. On the other hand, Coppola et al. [ 59 ] reported that their CS rate was not significantly reduced in the planned ECV group, even after adjustments were made for age, parity and previous CS delivery. Thus, each perinatal centre should implement an appropriate and coherent policy in accordance with the prevalence of pathologies in the population.

Towards a consensus for a global shared vision and management of term breech presentation that could include the following

A policy of breech presentation screening at 36 weeks of gestation is efficient and cost effective [ 60 ].

Such screening should allow timely ECV and a careful evaluation of potential underlying antenatal risks, considering obstetric history, estimated foetal weight/growth and potential gestational disorders [ 23 , 24 , 25 , 26 , 27 , 29 ].

Foetal weight estimates based on clinical and ultrasound examinations are essential, despite the large confidence interval of all available algorithms for producing such estimates. Vaginal birth may be excluded when the estimated foetal weight approximates the upper limit used for selection in most national guidelines (3800 g) [ 18 , 19 , 20 ], particularly in the absence of previous successful vaginal delivery.

Before vaginal delivery is considered, clinical pelvic examination is universally recommended to rule out pathological pelvic contraction. Radiologic or magnetic resonance imaging (MRI) pelvimetry is not universally conducted [ 20 , 23 , 24 , 31 , 32 ]. However, Van Loon et al. [ 33 ] demonstrated in a randomized controlled trial that the use of MRI pelvimetry in breech presentation at term allowed better selection of delivery route, with a significantly lower emergency CS rate. More specifically, several recent studies [ 34 , 35 ] have evaluated the contribution of pelvimetry and found that MRI pelvimetry provided useful criteria for the preselection and counselling of women with breech presentation and the desire for vaginal delivery. Therefore, pelvimetry is diversely used in Europe for the preselection and counselling of women (particularly nulliparous women) with breech presentation and is specifically used in regions where vaginal delivery is still considered an option [ 35 ].

In cases of failed ECV with persistent breech presentation, this policy should allow customized care tailored to each situation in the last weeks of pregnancy.

A discussion with the informed patient is essential. One must thoroughly consider the experience of the health care team/the availability of clinical skills required for conducting a vaginal breech delivery and carefully select women who are eligible for planned vaginal delivery (considering obstetric history and the criteria described above for the choice between planned vaginal and CS deliveries) [ 20 , 23 , 24 , 26 , 28 ].

Regardless of the planned mode of delivery [ 22 ], adequate follow-up during the last weeks of pregnancy is mandatory, with particular consideration of possible associated underlying disorders (particularly foetal growth restriction or excessive foetal weight in cases of gestational diabetes mellitus) [ 24 , 25 , 26 ]. Thus, the foetal weight estimation should be carefully considered in the 37th week of gestation, even in cases of minor glycaemic disorder, with regular reassessments and a plan for CS delivery if the patient remains pregnant for many more weeks and if foetal weight estimates reach approximately 3600–3800 g.

If vaginal delivery is planned, careful labour management by a skilled team is needed, accompanied by continuous foetal heart rate monitoring [ 36 ] and a particular focus on the rate of progress in the second delivery stage [ 37 ]. When such conditions are not or cannot be fulfilled, a planned CS may be the best choice.

When a CS has been planned, adequate follow-up during the last weeks of pregnancy and careful calculation of the delivery date are needed, taking into account possible comorbidities and gestational disorders.

Term breech presentation is a condition for which personalized obstetrical care is particularly needed. The best way is likely to be as follows: first, efficiently screen for breech presentation at 36–37 weeks of gestation; second, thoroughly evaluate the maternal/foetal condition, foetal weight and growth potential, and the type (frank, complete, or footling) and mobility of breech presentation; and three, consider the obstetric history and pelvic size/conformation. The management plan, including ECV and follow-up during the last weeks, should then be organized taking into account antenatal risk factors on a case-by-case basis by a skilled team after informing the woman, discussing her personal situation and criteria and helping her make a rational decision. Foetal overgrowth or growth restriction and/or oligohydramnios may necessitate timely CS, and the mode of delivery should be re-evaluated as necessary according to obstetric conditions (e.g., estimated foetal weight and Bishop score).

Availability of data and materials

Not applicable.

Abbreviations

American College of Obstetricians and Gynecologists

Caesarean section

External cephalic version

International Federation of Gynecology and Obstetrics

Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Royal College of Obstetricians and Gynaecologists

• Severe maternal morbidity

Society of Obstetricians and Gynaecologists of Canada

Term breech trial

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Department of Obstetrics and Gynecology, Sorbonne Paris Nord University, Assistance Publique – Hopitaux de Paris, Avenue du 14 juillet, Hôpital Jean Verdier, 93140, Bondy Cedex, France

Lionel Carbillon

Department of Obstetrics and Gynecology, Assistance Publique – Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France

Lionel Carbillon, Amelie Benbara, Ahmed Tigaizin, Rouba Murtada, Marion Fermaut, Fatma Belmaghni, Alexandre Bricou & Jeremy Boujenah

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Study conception and design: LC, AB, JB, AT, FB, AB. Analysis and interpretation of data: LC, JB. Drafting of manuscript: LC. Critical revision: LC, JB, RM, MF. The authors read and approved the final manuscript.

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Carbillon, L., Benbara, A., Tigaizin, A. et al. Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies. BMC Pregnancy Childbirth 20 , 263 (2020). https://doi.org/10.1186/s12884-020-2831-4

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DOI : https://doi.org/10.1186/s12884-020-2831-4

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• Term breech delivery
• Small-for-gestational-age
• Foetal growth restriction
• Oligohydramnios
• Delivery route
• Perinatal mortality
• Perinatal morbidity

BMC Pregnancy and Childbirth

ISSN: 1471-2393

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for vertex presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Peer-reviewed

Research Article

Maternal and neonatal outcomes associated with breech presentation in planned community (home and birth center) births in the United States: A prospective observational cohort study

Roles Conceptualization, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliations Division of Advanced Nursing Practice, School of Nursing, Rutgers University, Newark, NJ, United States of America, Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States of America

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliation Epidemiology Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, United States of America

Roles Conceptualization, Funding acquisition, Writing – review & editing

Affiliation Department of Anthropology, Oregon State University, Corvallis, OR, United States of America

Roles Conceptualization, Funding acquisition, Resources, Supervision, Visualization, Writing – review & editing

* E-mail: [email protected]

Affiliation School of Nursing, Vanderbilt University, Nashville, TN, United States of America

• Robyn Schafer, 
• Marit L. Bovbjerg, 
• Melissa Cheyney, 
• Julia C. Phillippi

• Published: July 22, 2024
• https://doi.org/10.1371/journal.pone.0305587
• Reader Comments

Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling)

Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats)

Planned community birth (homes and birth centers), United States

Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset

Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes

Main outcome measures

Maternal : intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture

Neonatal : transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death

One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7–10.4 and OR 18.6, 95% CI 15.9–21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4–16.3), even after congenital anomalies were excluded.

Conclusions

All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.

Citation: Schafer R, Bovbjerg ML, Cheyney M, Phillippi JC (2024) Maternal and neonatal outcomes associated with breech presentation in planned community (home and birth center) births in the United States: A prospective observational cohort study. PLoS ONE 19(7): e0305587. https://doi.org/10.1371/journal.pone.0305587

Editor: David Desseauve, Lausanne University Hospital: Centre Hospitalier Universitaire Vaudois (CH), FRANCE

Received: September 1, 2023; Accepted: June 1, 2024; Published: July 22, 2024

Copyright: © 2024 Schafer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: MANA Stats data are available to researchers with an approved data use agreement. Researchers can apply for access to use MANA Stats data by emailing [email protected] .

Funding: Marit L. Bovbjerg and Melissa Cheyney received funding from the United States National Institute of Health (Grant R03HD096094) towards this research effort. The funders played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

There has been a recent increase in breech birth in community settings (homes and birth centers) in the United States [ 1 ]. This is despite research demonstrating increased risk of intrapartum or neonatal death (16.8/1000 adjusted odds ratio [aOR] 8.2, 95% CI, 3.7–18.4) [ 2 ] in breech community births and consensus obstetric and midwifery recommendations that classify breech presentation as a contraindication to home birth [ 3 , 4 ]. Since 2000, planned cesarean has been the standard of care for breech presentation, following a landmark large-scale, randomized controlled trial (the Term Breech Trial) [ 5 ] and subsequent American College of Obstetricians and Gynecologists (ACOG) committee opinion [ 6 ] recommending planned cesarean delivery for all singleton term breech fetuses. However, more recent research has called those recommendations into question [ 7 – 12 ], concluding that although risk of adverse outcomes is higher in planned vaginal breech birth than planned cesarean, the absolute risk is quite low [ 13 – 16 ]. Internationally, support for vaginal breech birth is increasing [ 17 – 20 ], but nearly all breech fetuses (95.5%) in the US are born via cesarean [ 1 , 13 , 14 , 21 ]. ACOG committee opinion now recommends that for a term, singleton fetus, planned vaginal breech birth “may be reasonable under hospital-specific protocol guidelines for eligibility and labor management” [ 22 ]. However, hospital-based care for planned vaginal breech birth in the US is very difficult to obtain, in part due to a lack of skilled providers and medicolegal concerns [ 22 – 24 ], leading some individuals to seek care in community-based settings (homes and birth centers) [ 25 – 27 ].

Breech presentation affects approximately 3–4% of term pregnancies, and community births currently comprise about 2% of US births [ 28 , 29 ]. Based on birth certificate data from the National Center for Health Statistics, rates of US community births rose 33.2% from 2019 to 2022, including a 61.7% increase in breech births (n = 423 in 2019, n = 684 in 2022), in tandem with a decrease in hospital births [ 1 ]. In 2022, 12.5% (n = 488) of all reported singleton, term (greater than or equal to 37 + 0/7 weeks’ gestation) vaginal breech births in the US occurred in a community birth setting [ 1 ]. Research has established that intrapartum and neonatal death rates are higher in breech birth than cephalic births [ 2 ], but little is known about neonatal and maternal outcomes associated with breech presentation managed in community birth settings.

Data is also limited about maternal and neonatal outcomes based on type of breech presentation. Breech presentation is classified based on the position of the lower fetal extremities (see Table 1 ). Breech presentation nomenclature has been applied inconsistently in research and clinical practice recommendations, and there is ambiguity about variations of presentation types (such as partial flexion, location of feet alongside or just below the buttocks, or dynamic presentations that change during labor) [ 5 , 15 , 18 , 30 – 32 ]. Alternative nomenclatures have been proposed, but none have gained widespread acceptance [ 33 , 34 ]. Footling or kneeling breech presentation is generally considered a contraindication to vaginal birth due to increased risk of perinatal morbidity from umbilical cord prolapse or head entrapment leading to hypoxic injury [ 17 – 19 , 22 ]. However, there is limited evidence to support this recommendation since, with rare exceptions [ 30 , 35 ], vaginal breech trials historically have excluded (or not reported data regarding) footling or kneeling presentations [ 5 , 15 , 16 , 36 , 37 ]. Research that examines potential differences in community birth outcomes associated with type of breech presentation is needed to guide informed decision-making and optimize perinatal outcomes [ 2 ]. The purpose of this study was to analyze associations between breech birth and maternal and neonatal outcomes compared to cephalic presentations in planned community births and assess differences in outcomes associated with type of breech presentation.

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https://doi.org/10.1371/journal.pone.0305587.t001

Materials and methods

This cohort study used registry data (birth years 2012–2018) from the Midwives Alliance of North America Statistics Project (MANA Stats). MANA Stats includes extensive prenatal, birth, and postpartum data from individuals who received care from midwives in community birth settings in the United States. Individuals are prospectively enrolled in the registry at the onset of care in pregnancy with informed consent, and midwives enter data throughout perinatal care. MANA Stats development, data collection protocols, and evidence of reliability and validity are described elsewhere [ 40 , 41 ]. Ethical approval was received from Oregon State University’s IRB. All pregnant persons and midwives gave informed consent for research participation.

MANA data were accessed July 1, 2019. The study sample (N = 71,943) included all singleton, term births for individuals who planned community birth at the onset of labor and had a documented fetal presentation at birth ( Fig 1 ). Pregnancies missing information on fetal presentation at birth were excluded, as were persons who changed their intended site of birth to a hospital setting prior to onset of labor. Both vaginal and cesarean births were included. The main exposure of interest was breech presentation at birth (n = 695) in comparison to cephalic presentation, subdivided by type of breech presentation as defined by the data set variable “breech presentation at birth” as frank, complete, footling, kneeling, or unknown. No formal definitions of breech types were provided to midwives entering data into the registry; those who were uncertain could contact MANA Stats support staff for assistance.

https://doi.org/10.1371/journal.pone.0305587.g001

We explored associations between breech presentations at time of birth and multiple perinatal outcomes including durations of labor stages and membrane rupture. Labor stages were defined in the MANA Stats system as follows: first stage as the interval between frequent, intense contractions and onset of pushing; second stage as the start of active pushing efforts until birth of the neonate; and third stage as time from birth of the neonate until placental expulsion, as described in prior publications [ 42 ]. The management of impossible or improbable duration values are described in supplemental materials ( S1 Table ). Because this was a cohort of planned community births, intrapartum or postpartum transfer to hospital within six hours after birth was assessed, along with the reason(s) for transfer and urgency. Determination of indication(s) for transfer and associated urgency were based on assessment of the transferring midwife. We also analyzed maternal hospitalization in the first six weeks postpartum, including new admissions following community birth and postpartum readmissions. Finally, we evaluated adverse maternal outcomes, including severe (i.e., third- or fourth-degree) perineal laceration, retained placenta, and obstetric hemorrhage (defined as ≥1000 mL and/or diagnosed hemorrhage regardless of estimated blood loss) [ 43 ].

Neonatal outcomes included transfer to hospital in the first six hours of life (including indications and urgency), hospitalization (any) and/or NICU admission in the first six weeks of life (whether primary or readmission), umbilical cord prolapse, birth injury (defined as “skeletal fracture, peripheral nerve injury, and soft tissue or solid organ hemorrhage requiring intervention”), and intrapartum or neonatal death up to six weeks. Because term breech presentation is associated with congenital anomalies [ 44 – 46 ], we also assessed the presence of congenital anomalies (diagnosed antenatally or in the first six weeks of life) and explored deaths associated with anomalies separately. For every intrapartum or neonatal death, we explored free-text data entered by the community birth midwives describing the clinical course and circumstances surrounding care and provided brief case summaries.

Statistical analyses were performed using SPSS V 24.0.0.0 (IBM Corporation, Armonk, NY, USA) and R version 3.3.2 (R Foundation for Statistical Computing, Vienna, Austria). Initial analysis compared all types of breech presentation, collectively, to cephalic presentation. Analyses were then repeated to compare outcomes by presentation type. Medians and interquartile range are reported for labor durations and frequencies for all other outcomes. Because multivariable models were not possible due to low event counts for adverse outcomes, bivariable analyses were performed. We reported counts and proportions, including odds ratios (ORs) and confidence intervals (CI) for outcomes with five or more events in both comparison groups. Standard bivariable statistics were used to explore associations. We used unadjusted logistic regression models to calculate ORs and 95% CIs for categorical outcomes and the Kruskal-Wallis test to assess associations between breech presentation and labor duration, stratified by parity.

To contextualize our study sample, we compared the overall proportion of breech presentation to the expected proportion in the general US childbearing population based on vital statistics data (2016–2021) [ 47 ]. With the understanding that maternity care policies related to breech birth care may affect access to care and health outcomes [ 48 ], we also explored the two most frequent outcomes (cesarean and intrapartum transfer) for both cephalic and breech presentation stratified by covariables of planned site of community birth (i.e., home or birth center) and region of the country. Finally, since there is evidence that the level of integration of community birth providers into regional health systems affects maternal and neonatal birth outcomes [ 49 ], we explored associations state-level midwifery care integration scores (defined by Vedam et al., 2018) as an additional covariable in this analysis.

In this sample of 71,943 individuals, 1% (n = 695) gave birth to a term, singleton, breech neonate. Incidence of breech births in this low-risk sample of planned community births was, predictably, lower than the rate of 2.8% found the general US childbearing population (based on term, singleton births with known presentation from 2016–2021). As shown in Table 2 , demographic characteristics of individuals in this sample who experienced breech birth were generally similar to those with a cephalic birth, except for increased likelihood of being nulliparous (48.7% breech, 32.6% cephalic) and not eligible for low-income public health insurance (19.5% breech, 23.2% cephalic). Of the 695 breech neonates in this sample, the majority presented frank breech at birth (57.0%, n = 396), followed by complete (19.3%, n = 134), footling (17.7%, n = 123), and kneeling (0.7%, n = 5) presentations. Type of breech presentation was unknown in 5.3% (n = 37) of births.

https://doi.org/10.1371/journal.pone.0305587.t002

Associations between breech presentation and maternal and neonatal outcomes are presented in Table 3 , with reasons for transfer detailed and compared in Table 4 . Nearly half (42.4%) of all breech neonates in planned community births were born via cesarean (versus 3.8% for cephalic), and, relatedly, more individuals with a breech fetus transferred from community birth settings to the hospital in the intrapartum period (OR 9.0, 95% CI 7.7–10.4). Midwives classified more breech intrapartum transfers as urgent (46% v. 17%, p < 0.001), with malpresentation/malposition (85%) being the most common reason for intrapartum transfer. Multiple indications for transfer were commonly cited. Other than cord prolapse and fetal malpresentation, all other reasons for transfer were more common among cephalic labors. After intrapartum transfer (n = 344), 50 breech neonates were born vaginally (14.5%, vs. 61.4% of cephalic intrapartum transfers) in hospital settings. Vaginal hospital births included 30 frank breech, 7 complete, 12 footling, and 1 unknown breech type.

https://doi.org/10.1371/journal.pone.0305587.t003

https://doi.org/10.1371/journal.pone.0305587.t004

Maternal postpartum transfers were also more likely to be considered urgent in breech births (OR 2.7, 95% CI 1.5–4.6), even though prevailing maternal indications for transfer (including hemorrhage, laceration repair, and retained placenta) were more common in the cephalic group. Neither postpartum hemorrhage nor maternal hospitalization increased significantly with breech presentation compared to cephalic. There were insufficient events of operative births (i.e., forceps) (n = 4) or retained placenta (n = 7) for analysis.

Distributions of labor duration variables are shown in Fig 2 , stratified by presentation and parity. Median active labor for breech fetuses among nulliparas was shorter than cephalic fetuses (406 vs. 480 minutes), but the opposite was true for multiparous individuals (228 breech vs. 207 cephalic). There were no significant differences in duration of second or third stages based on fetal presentation, although breech labors were associated with significantly longer durations of membrane rupture for both nulliparas (median 336 minutes for breech vs. 268 cephalic) and multiparas (84 breech vs. 31 cephalic).

https://doi.org/10.1371/journal.pone.0305587.g002

For neonates, breech presentation was associated with increased odds of neonatal transfer, NICU admission, and birth injury (OR 4.7, 95% CI 3.1–7.0; OR 2.6, 95% CI 1.9–3.5; and OR 7.9, 95% CI 4.7–13.2, respectively) ( Table 3 ). There was no association between presentation at birth and neonatal hospitalization. Regarding indications for neonatal transfer ( Table 4 ), breech neonates were more likely to transfer for birth injury (18.5% vs. 3.5%) and “other” (not listed) reasons (55.6% vs. 30.9%) and less likely to transfer for respiratory distress (40.7% vs. 60.7%). Breech births were also more likely to experience umbilical cord prolapse (2.2% v. 0.1%, OR 32.2, 95% CI 18.0–57.7).

There was also a substantive increase in odds of intrapartum or neonatal death for the breech fetus (OR 8.5, 95% CI 4.4–16.3). Although based on only ten perinatal deaths (five intrapartum and five neonatal), this association persisted even when deaths related to congenital anomalies were excluded (OR 8.3, 95% CI 4.0–17.1). Deaths (described in S2 Table ) were attributed to congenital anomalies (n = 4), head entrapment (n = 3), cord prolapse (n = 2), and unknown causes (interoperative death, suspected placental abruption) (n = 1). Several intrapartum/neonatal deaths were complicated by late diagnosis of breech presentation and inefficient transfer of care including medical errors by emergency medical services (EMS), delays in hospital assessment and treatment, and conflicts with EMS or hospital staff. It is also worth noting that intrapartum/neonatal deaths included several instances of late onset of community-based care, with the midwives describing assuming responsibility for antepartum care only after hospital providers declined care for planned vaginal birth due to breech presentation in the absence of other risk factors.

Maternal and neonatal outcomes stratified by type of breech presentation are shown in Table 5 . For many outcomes, the small sample size of breech births and correspondingly low event counts preclude firm conclusions; however, a few patterns do emerge from the limited data. Rates of intrapartum transfer and cesarean birth are similar across all breech types, and postpartum hemorrhage was less common with frank breech (3.3% frank vs. 6.0% complete, 7.0% footling/kneeling). Neonatal transfers, hospitalization, and NICU admissions were twice as common in footling/kneeling presentations. Umbilical cord prolapse was also significantly more common, occurring in 7.3% of footling/kneeling breech births (0.8% frank, 2.3% complete); however, perinatal death was half as likely (7.8/1000 footling/kneeling vs. 20/1000 frank, 22/1000 complete)—a finding that should be interpreted with caution given the low incidence of death (n = 1) in the footling/kneeling group.

https://doi.org/10.1371/journal.pone.0305587.t005

Finally, analysis of contextual variables ( S3 Table ) found higher rates of cesarean and intrapartum transfer for breech labors in the New England region (OR 17.6, 95% CI 7.6–40.9 and OR 47.2, 95% CI 20.1–110.7, respectively) compared to other regions of the country. There were no substantive differences in outcomes based on planned site of community birth (i.e., home or birth center) or level of integration of community birth midwifery services into the healthcare system, as defined by Vedam et al.[ 49 ]

Among this sample of planned community births, breech presentation was associated with high rates of intrapartum transfer and cesarean birth (OR 9.0 and 18.6, respectively) and no increased risk of maternal hospitalization or postpartum hemorrhage. Associations with nearly all assessed adverse neonatal outcomes were increased in breech births, including transfer, NICU admission, and birth injury. Umbilical cord prolapse occurred in 2.2% of breech births (OR 32.2, 95% CI 18.0–57.7). There was a high rate of intrapartum and neonatal death (14.4/1000, OR 8.5, 95% CI 4.4–16.3), which persisted even after excluding congenital anomalies.

All types of breech presentation carry additional risk for adverse neonatal outcomes. Although sample sizes precluded meaningful analysis of perinatal outcomes associated with type of breech presentation, our findings support existing research that increased incidence of umbilical cord prolapse in footling/kneeling breech presentations may not be associated with increased risk of severe complications [ 50 ], though this result should be interpreted with caution. Labor duration was not affected by type of breech presentation, as consistent with prior findings [ 51 ]. Although there was some regional variation in rates of maternal transfer and cesarean, there were no substantive differences in outcomes based on parity, planned site of birth, or level of care integration of community-based midwifery services.

Due to logistical and ethical concerns about randomizing individuals to site or mode of birth [ 10 , 52 , 53 ], assessment of outcomes associated with breech presentation relies primarily on observational evidence. This descriptive analysis is useful for guiding decision-making for breech labor and birth. The size and scope of this dataset are a strength of this study, with a large sample of individuals across community birth settings throughout the United States and high rates of participation in data collection from community midwives (>95%) [ 40 ]. Prospective enrollment in pregnancy ensured that all birth outcomes were included, thereby minimizing selection bias and potential underreporting of adverse outcomes [ 40 ]. Additionally, this dataset includes vaginal breech births and footling/kneeling presentations, which are often excluded from research.

Despite these strengths, there are also several limitations to the research based on this dataset. First, because participation in data collection is voluntary, outcomes may differ between providers who participate in data collection and those who do not. Second, as with any dataset, research findings are limited by the existing variables and their definitions. For example, because community birth providers avoid frequent or unnecessary cervical examinations, the dataset defined onset of second stage by initiation of pushing (rather than with onset of full cervical dilation as it is commonly defined). Although these definitions are used elsewhere in the literature [ 42 ], these findings may not correlate exactly to other studies exploring labor durations. Similarly, the lack of variables regarding comprehensive clinical and environmental factors prohibited investigation of predictive factors associated with breech birth outcomes. For example, we could not distinguish between planned and unplanned breech births, assess relationships with external cephalic version, determine when breech presentation was identified or whether a skilled breech attendant was present, or correlate outcomes with regulatory scope of practice restrictions, such as state regulations that limit community birth providers’ care for breech labors.

One additional limitation of this study is the possibility that not all presentation types were classified accurately. In community birth settings, there is rarely access ultrasound technology to confirm presentation, and evidence has demonstrated poor reliability in determining presentation by physical examination alone [ 54 ]. Due to constraints of existing breech nomenclature, there was also potential for unreliable classifications of presentation variants (such as when the hips and knees are incompletely flexed or feet are located alongside or just below the buttocks) or those that changed during labor (such as a complete breech fetus who extends a leg). Finally, because community birth care utilizes low levels of intervention, findings from breech community birth may not be generalizable to high-resource hospital settings [ 14 ].

Interpretation and implications

Findings from this study reinforce existing evidence of increased risk of adverse neonatal outcomes in breech community birth [ 2 , 55 , 56 ]. Although many emergent interventions and technologies are not readily accessible in community births, the physiologic approach exemplified in these settings is widely considered by expert breech clinicians to be optimal for perinatal outcomes [ 57 , 58 ]. However, even physiologic management in a low-risk population does not appear to circumvent risks to the breech neonate.

This research has implications for clinical practice, health care policy, and future research. Pregnant people should be counselled about the increased risk of adverse neonatal outcomes for breech fetuses in planned community births. These risks should be considered in context of the risks and benefits associated with sites and modes of birth, including risks to future pregnancies and individuals’ unique needs, preferences, values, and risk tolerance [ 13 , 17 ]. Care providers in all settings should take steps to identify breech presentation at term and provide evidence-based information about breech birth outcomes to ensure informed choice. Skills in breech assessment and management should be incorporated into midwifery and obstetric training to optimize outcomes. Recognizing that breech community births will inevitably occur, both accidentally and intentionally, community and hospital birth providers should develop guidelines to identify and manage complications and provide timely and efficient transfer when needed [ 59 ].

Community birth is not well integrated into the health care system throughout the United States [ 49 , 60 ], and this lack of coordination of care across birth settings was evident in several intrapartum and neonatal deaths in this sample. In addition, it was noted in a few cases that individuals were late to community-based care after they were declined care for planned hospital vaginal birth due to breech presentation in the absence of other risk factors. Community birth in the presence of high-risk conditions often indicates a failure of the medical system to meet patient’s needs for less interventive care and autonomy in decision-making [ 27 , 61 – 64 ]. Restrictive policies preventing hospital providers from offering care for planned vaginal breech birth to appropriate candidates should be eliminated as they impede patient autonomy and access to care and inadvertently push more medically complex births into community settings [ 24 , 26 , 57 , 59 , 65 , 66 ].

In prior published analyses using this data set, members of this research team recommended that, due to increased risk of adverse outcomes in community birth, breech presentations were better managed in birth settings with immediate access to hospital staff and facilities [ 2 ]. However, despite US recommendations supporting care for planned vaginal breech birth for appropriately screened candidates in hospitals [ 17 , 22 ], access to vaginal breech birth and skilled breech providers in hospitals remains limited [ 25 , 26 ]. Findings from this study, along with the recent increase in US breech community births, reinforce consensus recommendations that US hospitals have a “clear and urgent responsibility” [ 25 ] to increase access to care for planned vaginal breech given the increased risk of adverse perinatal outcomes associated with breech community birth compared to cephalic presentations. Policies and medicolegal reforms that incorporate best available evidence and center the birthing person and their rights to autonomy are necessary to improve maternal and neonatal outcomes and support informed choice for breech pregnancy and birth.

Breech presentation in all birth settings is associated with increased risk of adverse outcomes compared to cephalic presentation, and further research is needed to explore maternal and neonatal outcomes in matched cohorts of breech births in different settings with skilled breech providers. There is a need for development and adoption of a consistent and well-defined breech nomenclature to minimize ambiguity between presentation types and facilitate evidence synthesis. Future studies should explore outcomes based on type of breech presentation using this standardized nomenclature and report outcomes according to a standardized core outcome set (e.g., Breech-COS, currently in development) [ 67 ]. Research on breech labor outcomes is needed to guide decision-making, given that comparisons of prelabor cesarean to planned vaginal birth are not generalizable to laboring persons facing either emergent cesarean or unplanned vaginal breech birth. Researchers should assess the proportion of breech presentations correlated with underlying conditions (i.e., fetal growth restriction, congenital anomalies, oligohydramnios, placenta previa, maternal gestational diabetes mellitus or hypertensive disorders, uterine malformation, or history of cesarean) [ 45 , 68 ] and investigate how these conditions affect morbidity and mortality, regardless of mode or site of birth. Finally, research is needed to explore the barriers and facilitators of breech birth care in the United States to guide recommendations to improve access to quality care [ 26 ].

In planned community births, all types of breech presentation pose substantial risk of adverse outcomes, including high rates of intrapartum and neonatal death. This research provides evidence about breech labor in community birth settings and adverse maternal and neonatal outcomes associated with breech birth to inform decision-making. There is a need for increased training and research on vaginal breech birth. Reforms are needed to ensure accessible, high-quality care for planned vaginal breech birth in US hospitals.

Supporting information

S1 appendix. strengthening the reporting of observational studies in epidemiology (strobe) statement..

https://doi.org/10.1371/journal.pone.0305587.s001

S1 Table. Management of impossible and improbable data for labor duration variables.

https://doi.org/10.1371/journal.pone.0305587.s002

S2 Table. Details for the 10 breech intrapartum/neonatal deaths.

https://doi.org/10.1371/journal.pone.0305587.s003

S3 Table. Cesarean and intrapartum transfer, by fetal presentation (stratified by region, level of care integration, and planned site of birth).

https://doi.org/10.1371/journal.pone.0305587.s004

Acknowledgments

The authors gratefully acknowledge the midwives who contributed data to the MANA Stats Project.

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Elective Caesarean Section for Breech Presentation

If an ecv has been considered inappropriate or proved to be unsuccessful, it is important for you to consider the advantages and disadvantages of both planned (elective) caesarean section and planned vaginal breech birth., caesarean section.

• A planned caesarean section is safer than an emergency caesarean section, in the event of a planned vaginal breech birth being unsuccessful, for mother.

• Having a caesarean section creates a scar on your uterus (womb) and as a consequence there are greater risks associated with future pregnancies.

These are due to:

- a small risk of scar separation (please discuss this with your obstetrician)

- the risk of developing problems with your placenta which can cause bleeding

- placenta praevia (when your placenta is low down in the uterus) or

- placenta accreta (when the placenta grows into the scar tissue)

-Caesarean section also increases the risk of: infection, bleeding and thromboembolism

A planned caesarean due to breech is usually carried out around the 39 weeks of pregnancy and the procedure is fully explained. Further information regarding caesarean section can be accessed in the Caesarean Section part of our website.

Additional care after your baby is born

When babies have been in a breech position after 36 weeks of pregnancy there is a slightly increased risk of unstable hips. Your baby will be offered a hip assessment as part of their 'first medical examination' to assess the stability of their hip joints. An ultrasound scan at around six weeks of age will also be arranged.

Going into labour before the date of your caesarean section

Approximately 5% (five in 100) of women will go into labour before the date of their planned caesarean section. This may result in a vaginal birth if things progress quickly, but if time allows a caesarean section will be carried out as planned.

It is important that you discuss the implications of these advantages and disadvantages with your obstetrician and consider your future pregnancy plans.

'I would like to thank all the staff for my treatment and their professionalism.'

Patient, Cardiology Department, Bishop Auckland Hospital

Breech presentation

Highlights & basics.

• Diagnostic Approach
• Risk Factors

History & Exam

• Differential Diagnosis
• Tx Approach
• Emerging Tx
• Complications

PATIENT RESOURCES

• Patient Instructions

Breech presentation refers to the baby presenting for delivery with the buttocks or feet first rather than head.

Associated with increased morbidity and mortality for the mother in terms of emergency cesarean section and placenta previa; and for the baby in terms of preterm birth, small fetal size, congenital anomalies, and perinatal mortality.

Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies.

Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned cesarean section, the optimal gestation being 37 and 39 weeks, respectively.

Planned cesarean section is considered the safest form of delivery for infants with a persisting breech presentation at term.

Quick Reference

Key Factors

Other Factors

Diagnostics Tests

Treatment Options

Epidemiology

Pathophysiology.

Key Articles

Impey LWM, Murphy DJ, Griffiths M, et al; Royal College of Obstetricians and Gynaecologists. Management of breech presentation: green-top guideline no. 20b. BJOG. 2017 Jun;124(7):e151-77. [Full Text]

Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev. 2015 Jul 21;(7):CD000166. [Abstract] [Full Text]

Royal College of Obstetricians and Gynaecologists. External cephalic version and reducing the incidence of term breech presentation. Mar 2017 [internet publication]. [Full Text]

Cluver C, Gyte GM, Sinclair M, et al. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database Syst Rev. 2015 Feb 9;(2):CD000184. [Abstract] [Full Text]

de Hundt M, Velzel J, de Groot CJ, et al. Mode of delivery after successful external cephalic version: a systematic review and meta-analysis. Obstet Gynecol. 2014 Jun;123(6):1327-34. [Abstract]

Referenced Articles

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23. Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ. 2001 May 5;322(7294):1089-93. [Abstract] [Full Text]

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25. Impey LWM, Murphy DJ, Griffiths M, et al; Royal College of Obstetricians and Gynaecologists. Management of breech presentation: green-top guideline no. 20b. BJOG. 2017 Jun;124(7):e151-77. [Full Text]

26. Royal College of Obstetricians and Gynaecologists. Antepartum haemorrhage: green-top guideline no. 63. November 2011 [internet publication]. [Full Text]

27. American College of Obstetricians and Gynecologists. Practice bulletin no. 175: ultrasound in pregnancy. Obstet Gynecol. 2016 Dec;128(6):e241-56. [Abstract]

28. Enkin M, Keirse MJNC, Neilson J, et al. Guide to effective care in pregnancy and childbirth. 3rd ed. Oxford: Oxford University Press; 2000.

29. Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2012 Oct 17;(10):CD000083. [Abstract] [Full Text]

30. Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev. 2015 Jul 21;(7):CD000166. [Abstract] [Full Text]

31. Royal College of Obstetricians and Gynaecologists. External cephalic version and reducing the incidence of term breech presentation. Mar 2017 [internet publication]. [Full Text]

32. Rosman AN, Guijt A, Vlemmix F, et al. Contraindications for external cephalic version in breech position at term: a systematic review. Acta Obstet Gynecol Scand. 2013 Feb;92(2):137-42. [Abstract]

33. ​American College of Obstetricians and Gynecologists. Practice bulletin no. 221: external cephalic version. May 2020 [internet publication]. [Full Text]

34. Bogner G, Xu F, Simbrunner C, et al. Single-institute experience, management, success rate, and outcome after external cephalic version at term. Int J Gynaecol Obstet. 2012 Feb;116(2):134-7. [Abstract]

35. Hofmeyr GJ. Effect of external cephalic version in late pregnancy on breech presentation and caesarean section rate: a controlled trial. Br J Obstet Gynaecol. 1983 May;90(5):392-9. [Abstract]

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• v.170(5); 2004 Mar 2

Planned elective cesarean section: A reasonable choice for some women?

A growing number of women are requesting delivery by elective cesarean section without an accepted “medical indication,” and physicians are uncertain how to respond. This trend is due in part to the general perception that cesarean delivery is much safer now than in the past and to the recognition that most studies looking at the risks of cesarean section may have been biased, as women with medical or obstetric problems were more likely to have been selected for an elective cesarean section. Thus, the occurrence of poor maternal or neonatal outcomes may have been due to the problem necessitating the cesarean delivery rather than to the procedure itself. The only way to avoid this selection bias is to conduct a trial in which women would be randomly assigned to undergo a planned cesarean section or a planned vaginal birth. When this was done in the international randomized Term Breech Trial involving 2088 women with a singleton fetus in breech presentation at term, the risk of perinatal or neonatal death or of serious neonatal morbidity was significantly lower in the planned cesarean group, with no significant increase in the risk of maternal death or serious maternal morbidity. 1

In response to the growing demand from women to have a planned elective cesarean section, the American College of Obstetricians and Gynecologists published a committee opinion 2 that states

If taken in a vacuum, the principle of patient autonomy would lend support to the permissibility of elective cesarean delivery in a normal pregnancy, after adequate informed consent. To ensure that the patient's consent is, in fact, informed, the physician should explore the patient's concerns. ... If the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean delivery would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery.

The Ethics Committee of the Society of Obstetricians and Gynaecologists of Canada is also preparing a statement.

What are the risks of cesarean delivery? The maternal mortality is higher than that associated with vaginal birth (5.9 for elective cesarean delivery v. 18.2 for emergency cesarean v. 2.1 for vaginal birth, per 100 000 completed pregnancies in the United Kingdom during 1994–1996). 3 Cesarean section also requires a longer recovery time, and operative complications such as lacerations and bleeding may occur, at rates varying from 6% for elective cesarean to 15% for emergency cesarean. 1 , 4 Having a cesarean delivery increases the risk of major bleeding in a subsequent pregnancy because of placenta previa (5.2 per 1000 live births) and placental abruption (11.5 per 1000 live births). 5 Among term babies, the risk of neonatal respiratory distress necessitating oxygen therapy is higher if delivery is by cesarean (35.5 with a prelabour cesarean v. 12.2 with a cesarean during labour v. 5.3 with vaginal delivery, per 1000 live births). 6 Also, a recent study has reported that the risk of unexplained stillbirth in a second pregnancy is somewhat increased if the first birth was by cesarean rather than by vaginal delivery (1.2 per 1000 v. 0.5 per 1000). 7 Lastly, birth by cesarean is not generally considered “natural” or “normal.”

What are the benefits of cesarean section? It may reduce the risk of urinary incontinence, which is a common postpartum problem. In one study of primiparous women, 26% had urinary incontinence at 6 months post partum, the rate being lowest with elective cesarean (5%), higher with cesarean during labour (12%), higher still following a spontaneous vaginal birth (22%) and highest following a vaginal forceps delivery (33%). 8 Although not as common as urinary incontinence, fecal incontinence, affecting about 4% of women giving birth, is usually a serious problem, and the risk may be reduced by cesarean section. 9 Other maternal benefits from cesarean delivery include avoidance of labour pain, alleviation of fear and anxiety related to labour or birth 10 , 11 and reduced worry about the health of the baby. 12 Also, some women may just prefer the convenience and control of being able to plan the precise timing of the birth. The baby may also benefit. The risk of an unexplained or unexpected stillbirth may be reduced by cesarean section, as may be the risk of complications of labour such as clinical chorioamnionitis, fetal heart rate abnormalities and cord prolapse. 1 , 13 Lastly, labour and vaginal birth, complete with hospital stay, continuous electronic fetal heart rate monitoring, induction or augmentation of labour, epidural analgesia, forceps delivery, episiotomy and multiple caregivers, may also not be considered “natural” or “normal.”

However, this issue involves more than a simple comparison of risks and benefits of cesarean and vaginal birth. Planning for a vaginal birth may result in an emergency cesarean section, which carries higher risks for the mother than if an elective cesarean had been undertaken. 3 , 14 For a term pregnancy with a breech presentation the risk of emergency cesarean is over 40%. 1 If the baby is in a cephalic presentation, the risk of emergency cesarean may be less than 5% for a multiparous woman in spontaneous labour at 37 weeks' gestation, and as high as 35% for a primiparous woman who is having labour induced at 42 weeks' gestation. 15 Other factors, such as maternal age, may also affect this risk. 16 If the mother has a vaginal birth, it may have required a forceps delivery or resulted in tearing of the anal sphincter, or both, thus increasing the risks of urinary and fecal incontinence. 17 Although pelvic floor muscle training may reduce the risk of postpartum incontinence, 18 these exercises are not always prescribed by obstetric care providers.

The important question, therefore, is whether a planned cesarean delivery will be more beneficial than harmful to a woman and her baby compared with a planned vaginal birth. To answer this question for women with a singleton fetus in breech presentation at term, we undertook the international randomized controlled Term Breech Trial involving 2088 women. 1 Most (90.4%) of the women randomly assigned to the planned cesarean group delivered by cesarean section; however, only 56.7% of the women randomly assigned to the planned vaginal birth group actually delivered vaginally, the others having complications that necessitated a cesarean section. Compared with planned vaginal birth, the policy of planned cesarean delivery reduced the risk of perinatal or neonatal death (0.3% v. 1.3%, p = 0.01) and the risk of perinatal or neonatal death or serious neonatal morbidity (1.6% v. 5.0%, p < 0.0001). There was 1 maternal death in the planned vaginal birth group. The risk of maternal death or serious short-term maternal morbidity was low among all women and not increased among women in the planned cesarean group (3.9% v. 3.2%, p = 0.35). 1 However, when these results were included in a Cochrane review with 2 other small randomized trials, the risk of short-term maternal morbidity was significantly higher with a policy of planned cesarean section than with planned vaginal birth (relative risk 1.29, 95% confidence interval 1.03–1.61). 19 On the basis of this information, the American College of Obstetricians and Gynecologists issued a committee opinion on breech delivery stating that “patients with a persistent breech presentation at term in a singleton gestation should undergo a planned cesarean delivery.” 20 And at 3 months after the birth, women in the planned cesarean group of the Term Breech Trial were less likely than women in the vaginal birth group to report urinary incontinence (4.5% v. 7.3%, p = 0.02). 12

Unfortunately, for women not having a breech birth, such as those pregnant with twins, women who have had a previous cesarean section, older women, those who are having their first baby, those with incontinence problems and women who are afraid of labour, we have little information on the true benefits and risks of planned elective cesarean section compared with planned vaginal birth. Randomized studies are underway involving women with twins and women who have had a previous low-segment cesarean section, but the findings will not be available for several years.

In the meantime, what should physicians do? Most women prefer to plan for a vaginal birth. 11 However, if a woman without an accepted medical indication requests delivery by elective cesarean section and, after a thorough discussion about the risks and benefits, continues to perceive that the benefits to her and her child of a planned elective cesarean outweigh the risks, then most likely the overall health and welfare of the woman will be promoted by supporting her request.

β See related article page 775

Competing interests: None declared.

Correspondence to: Dr. Mary E. Hannah, Director, University of Toronto Maternal Infant and Reproductive Health Research Unit, Centre for Research in Women's Health, 751–790 Bay St., Toronto ON M5G 1N8; fax 416 351-3771; [email protected]